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HEALTH SC)WC©L|BR{fA

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND AT
BALTIMORE

NOT TO CIRCULATE

Digitized by the Internet Archive
in 2016 with funding from

The National Endowment for the Humanities and the Arcadia Fund

https://archive.org/details/westvirginiamedi9011west

Volume 90 No. 1

West Virginia State Medical Association

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

HOT IN CIRC,

UNIVERSITY OF MARYLAND
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| EDITOR

itephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

ASSOCIATE EDITORS
John M. Hartman, M.D., Charleston
Joe N. Jarrett, M.D., Oak Hill
Robert J. Marshall, M.D., Huntington
David Z. Morgan, M.D., Morgantown
Louis C. Palmer, M.D., Clarksburg
Harvey D. Reisenweber, M.D., Martinsburg
Mabel M. Stevenson, M.D., Huntington

West Virginia Medical

OURNAL

Contents

Feature Articles

An overview of Medical Savings Accounts

RESIDENT EDITOR

Linn M. Mangano, M.D., Morgantown

f ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Published monthly by the West Virginia State
Medical Association under the direction of the
Publication Committee. Original articles are ac-
cepted on condition that they are contributed
solely to the West Virginia Medical Journal

Postmaster send form 3579 to the West
Virginia Medical Journal, 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1 ,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL JOURNAL

(ISSN 0043-3284) is published monthly by the
West Virginia State Medical Association, 4307
MacCorkle Avenue, S.E., Charleston, WV 25304.

Subscription Rates: $36 a year in the U.S.; $60
in foreign countries; $3 per single copy. Address
all communications to the West Virginia
Medical Journal, P O. Box 4106, Charleston,
WV 25364.

Due to increasing publication costs, the West
Virginia Medical Journal will honor no claims
for back issues for any reason, unless these
claims are received within a 6-month period
after issue of publication

Microfilm editions beginning with the 1972
volume are available from University Microfilms
International, 300 N. Zeeb Road, Ann Arbor,
Michigan 48106.

Health Access celebrates first year of service 7

Scientific Newsfront

Radiation therapy for stage 111 non-small cell lung cancer:

a curative treatment option 8

Serum ferritin and myocardial infarct 13

Manuscript Guidelines 15

President’s Page

When a reporter calls, call back! 16

Editorial

A special message about media relations 17

In My Opinion

Clinton’s health care plan deserves praise, much criticism . . 18

Special Departments

General News 22

Registration Notice About Mid- Winter Clinical Conference . . 25

News Briefs 26

Managed Care Workshop Registration Information 27

Continuing Medical Education 28

Medical Meetings/Poetry Corner 29

Bureau of Public Health News 30

Robert C. Byrd Health Sciences Center News 32

Marshall University School of Medicine News 34

Classified 37

January Advertisers 38

USPS 676 740
ISSN 0043 - 3284

Front Cover

Snowy fields on Bald Knob at Canaan Valley, W.Va.
in Tucker County. Photo courtesy of Steven J. Shaluta
Jr., West Virginia Division of Tourism and Parks.

JANUARY 1994, VOL. 90 5

Feature Articles

An overview of Medical Savings Accounts

Editor’s Note: The following text is from a White Paper
which the West Virginia State Medical Association is
preparing to educate members and the public about
medical savings accounts.

Physician members of the West Virginia State Medical
Association, are, like many citizens throughout this state
and across the nation, concerned about the future of
health care. Obviously, there are flaws in the system, but
Americans still enjoy the benefits of the world’s best
medical care. To change the way such care is provided
could destroy the quality of that care entirely.

Our challenge, then, is to correct those problems,
specifically access and cost, without damaging the core
component of our health care system - - choice. With that
goal in mind, the WVSMA has endorsed the philosophy of
Patient Power - - allowing individuals to make their own
decisions about what they need and want in medical care.

The specific recommendations that Patient Power
endorses are centered around the establishment of
individual Medical Savings Accounts (MSAs). These
accounts would allow individuals and families to
determine how their health care dollars are spent. The
accounts would be funded by an individual, an employer
or both. A portion of the money could be used to buy a
high deductible catastrophic insurance policy to cover the
individual or family for any major need, with the
remainder being available to pay for routine medical
expenditures while satisfying the deductible. Any money
remaining in the account at the end of each year could be
rolled-over and allowed to accumulate with interest for
future medical expenses. The funds set aside for the MSAs
would be exempt from state taxes, and if a federal
exemption is granted, free from federal taxes. Any interest
accrued on these funds would have the same tax
exemptions.

The premise behind MSAs is to allow individuals and
their families to buy policies appropriate for their
particular needs, instead of being forced to take a one-size
fits all mandated policy. By doing so, access will increase
because there will be more of an incentive for people to
obtain medical insurance because the MSAs earn interest
and are a stable source of income to pay for health care,
especially for long-term care.

Another positive aspect behind MSAs is that these
accounts allow the individual and his/her family the
freedom of choice to decide who will provide their care.
For example, if an individual with an MSA wants to
participate in a managed health care plan, that is his/her
decision. Additionally, the employer is not burdened with
the unnecessary paperwork of dealing with certain
providers or insurance companies.

Cost savings could also result for employers. Many
employers who do not offer health insurance have a
tremendous turnover rate. By making it more economical

to jointly provide coverage with their employees, the
employer’s costs for training employees would go down
because their turnover rate would decrease.

Additionally, with the establishment of Medical Savings
Accounts, portability of insurance will be provided and
pre-existing conditions should be eliminated.

To help you more fully understand Medical Savings
Accounts, the following questions and answers have been
provided by the Council For Affordable Health Insurance:
Q. Can the MSA be compatible with managed care
arrangements, and what is the mechanism by which
this can be done?

A. Yes. The MSA concept would work well with managed
care. For example, individuals can take a portion of
their MSA balance and purchase HMO or indemnity
coverage if they wish. Furthermore, it is increasingly
clear that managed care (such as individual case
management) is not particularly effective when used
for routine health services and works best for high cost
conditions for which there are alternative treatment
options. Insurers who include rigorous managed care
tools in their catastrophic umbrella policy will gain
price advantages over those who do not use these
tools. Competition will encourage continued efforts to
find the managed care techniques that reduce the costs
of catastrophic care.

Q. Is it likely that most people will choose to remain with
their traditional coverage because otherwise, they
would be exposed to the risk of paying medical
expenses in excess of the balances in their medical
savings account?

A. No, most people will likely choose to move to an MSA
arrangement for the following reasons:

1. The MSA is intended to be supplemented with a
catastrophic insurance policy. People would thus be
able to avoid the risk of paying medical expenses in
excess of the balances in their MSAs.

2. For most employees, the possiblity of building up
funds through an MSA with their employer’s money
will be far more attractive than the certainty that
they will not be able to do so under their current
policy.

3. Individuals will no longer have to forego treatment
because they cannot afford co-payments or
deductible requirements. In addition, costs will be
lower initially due to lower administrative expenses,
and over time would be less because of lower
utilization.

Q. Would all individuals be required to buy insurance?

A. No. We do not favor compulsory insurance. However,
with an attractive program like MSAs available, there
will be more incentive for young, healthy people to
participate. By not using all that’s available each year

6 THE WEST VIRGINIA MEDICAL JOURNAL

in their MSAs, people will see the savings grow every
year and money would be accessible for their medical
care.

Q. What would be done to assist lower-income families in
meeting their medical expenses?

A. Refundable tax credits and/or medical care vouchers
could be allowed for those individuals who would
need some assistance in meeting their medical
expenses.

Q. What changes, if any, would be made in the private
insurance market to ensure that individuals and
families could buy a health insurance policy from an
insurance carrier?

A. Small group reform measures such as full portability for
those with continuous coverage, renewability of
coverage, and limits on rate increases, which would
make coverage much more affordable.

Q. Where will the money come from for the tax
credits/vouchers?

A. The WVSMA recommends passing legislation

implementing a tobacco excise tax. Currently, state
excise taxes are only imposed on cigarettes. The
WVSMA supports taxing all tobacco products.
According to the West Virginia Tobacco Control
Coalition, by passing such legislation there would be
an increase in revenue in 1995 from the $31 million
from cigarettes only, to approximately $74 million from
all tobacco products.

As these questions and answers illustrate, through
Patient Power there is an alternative to improving our
health care system without major changes to the current
system -- which is recognized as the best in the world.

Health Access celebrates first year of service

In his speech at the celebration, AMA Trustee Dr. Michael Goldrich praised Health Access
staff members, volunteers and community leaders for their roles in making the clinic such a
success. Nancy Tonkin of the West Virginia Hospital Association (seated second from right)
was the other guest speaker for this special occasion.

Staff members and volunteers for
Health Access, Inc., Clarksburg’s free
clinic, gathered with members of the
community and a variety of special
guests at the Rose Garden Theater on
Sunday, November 7 to celebrate
caring for 1,500 patients during the
clinic’s first year of operation.

‘ The efforts of the Harrison County
Medical Society, the Harrison County
Medical Society Auxiliary local
business leaders and members of the
community have made this first year
for Health Access a phenomenal
success,” Aaron Taylor, the clinic’s
executive director said. ‘‘We have

been able to expand our services
dramatically since we opened last
October because of the generosity
and dedication of so many people
from all over the state and from every
aspects of the Clarksburg community.
We are very proud to now have a
full-time medical director, Dr. Suzanne
Goodyear, on staff, as well as a full-
time pharmacist, Marcy Mclntire.”

The annual meeting activities began
with the premiere of a special film
about Health Access which was
created by WDTV in Clarksburg.
Following this presentation, Senator
Jay Rockefeller delivered a special

Dr. Doug McKinney proudly accepts his
award for being named one of the
Physicians of the Year for Health Access,
Inc. Dr. McKinney and the other Physician
of the Year Dr. Paul Davis, care for patients
both at the clinic and at their offices and
serve on its board of trustees.

filmed congratulations to Dr. Louis
Ortenzio, the clinic’s founder and
chairman of the board, and everyone
attending the ceremony who helped
contribute to Health Access’ success.
The keynote addresses were then
delivered by AMA Trustee Dr. Michael
Goldrich and Nancy Tonkin of the
West Virginia Hospital Association.

Numerous awards were given at
the meeting to the clinics’ volunteers
who gave an incredible total of 10,427
hours of their time to the clinic before
and during the first year of operation.
Among those honored were Dr. Doug
McKinney and Dr. Paul Davis as
physicians of the year; and the
Harrison County Medical Society
Alliance members were named
Organization of the Year.

JANUARY 1994, VOL. 90 7

Scientific Newsfront

Radiation therapy for stage III non-small ce
lung cancer: a curative treatment option

B. R. COHEN, M.D.

Clinical Associate Professor of Radiology,
Department of Radiation Oncology,

West Virginia University School of
Medicine, Charleston Division, Charleston,
W.Va.

T. DAVID BAILEY, M.D.

behavior, it is divided into two
groups: small-cell lung cancer and
non-small cell lung cancer.
Approximately 75% of lung cancers
are of the non-small cell variety

(squamous carcinoma, adenocarcinoma]
and large-cell carcinoma) and 25% are
of the small-cell type.

Chemotherapy is the primary
treatment for small-cell lung cancer.

PGY2, Department of Medicine,

West Virginia University School of
Medicine, Charleston Division, Charleston,

W.Va.

ANDREW A. TALKINGTON, M.D.

PGY2, Department of Family Practice
West Virginia University School of
Medicine, Charleston Division, Charleston,
W.Va.

A. DON WOLFF, M.D.

Director, Seby B. Jones Regional Cancer
Center, Boone, N.C.

Abstract

This paper analyzes our
treatment results for a selected
group of Stage III non-small cell lung
cancer (NSCLC) patients treated
with irradiation alone. One, two and
five-year survival rates were 42%,
20% and 6% respectively. Survival
rates for patients with Stage IIIA
and Stage IIIB disease were similar.
Our results agree with the literature
and confirm that 5% of selected
patients with Stage III NSCLC will be
disease free and potentially cured,
five years after treatment with
irradiation.

Recurrence in the radiation field
continues to be a major problem for
patients with Stage III NSCLC,
accounting for the initial site of
failure in 40%-55% of patients.
Improvements in local control will
likely improve survival rates
somewhat ; but, because of the
marked propensity for these
cancers to ultimately metastasize,
significant improvement in survival
rates will only occur when effective
systemic therapy becomes available.

Introduction

Lung cancer (1) is a common and
deadly malignancy. Based on
histologic features and clinical

Table l. Current Staging System for Lung Cancer

Abridged AJCC (American Joint Committee on Cancer)

Primary Tumor

T, - Tumor <, 3 cm in size, not involving visceral pleura and located distal to mainstem bronchus

T2 - Tumor with any of the following : a) > 3 cm in size b) involving visceral pleura c) atelectasis
involving hilar region d) involving mainstem bronchus > 2 cm distal to carina

T3 - Tumor of any size involvmg any of the following: chest wall, diaphragm, mediastinal pleura,
pericardium or tumor in mainstem bronchus within 2 cm of carina or atelectasis of entire lung

T4 - Tumor of any size invading any of the following: mediastinal structures, vertebral body, carina
or a malignant pleural effusion

Regional Lymph Nodes

N0 - No nodal metastasis

N, - Metastasis in ipsilateral peribronchial nodes or ipsilateral hilar lymph nodes

N2 - Metastasis in ipsilateral mediastinal nodes or subcarinal lymph nodes

N3 - Metastasis in contralateral mediastinal nodes, contralateral hilar nodes or supraclavicular lymph nodes

Metastatic Disease

M, - Presence of metastatic disease

Stage Grouping

Stage I

N„

Stage II

T,.j

M„

Stage IIIA

T,3

No-2

M„

Stage IIIB

Any T

T„

Any N

Stage IV

Any T

Any N

8 THE WEST VIRGINIA MEDICAL JOURNAL

Table 2. Stage III Lung Cancer Patients
Distribution by TN Classification and Stage Subgrouping.

IIIA

IIIB

t,n2

t4n0

T3N„

t4n,

t3n,

t4n2

t3n2

Total Patients:

Stage

Table 3. Survival, Stage HIA vs Stage JL1LB

% Surviving at:

IIIA

IIIB

12 Months

50 (n= 14)

p = .196, NS’
32 (n=7)

18 Months

36 (n=10)

p = .171, NS’
18 (n=4)

(n)=Number of Patients Alive, p=Values of Significance, *NS = Not Statistically Significant

For non-small cell lung cancer,
surgery is the primary treatment for
resectable disease, and radiation
therapy is the primary treatment for
unresectable cancer. The term lung
cancer will refer to non-small cell lung
cancer throughout the rest of this
paper.

Approximately 125,000 cases of
lung cancer were diagnosed in 1992
(2). The current staging system for
lung cancer is shown in Table 1. At
presentation, approximately 1/3 of
patients have resectable cancer (Stage
I & II); 1/3 have metastatic disease
(Stage IV); and 1/3 have locally
advanced but non-metastatic disease
(Stage III). For each stage, the best
survival is seen in patients with a
performance status ranging from good
to excellent and with minimal or no
weight loss (1).

Cure rates for aggressively staged,
resected, pathologic Stage I lung
cancer are 60%-90% (1,3). For

resected pathologic Stage II disease,
the cure rate decreases to 30%-50%
(1,3), reflecting the negative influence
of lymph node involvement.

Patients with metastatic disease
(Stage IV) are incurable and
chemotherapy has shown minimal
benefit (1). Life expectancy for this
group of patients is approximately six
months and optimizing the quality of
survival is the main objective when
caring for these patients.

Most patients with Stage III lung
cancer are unresectable (1,3) and
radiation therapy is standard
treatment. These patients can be
expected to achieve one, two and
five-year survival rates of
approximately 40%, 20% and 5%
respectively (1,4, 5, 6).

Based on resectability, Stage III
lung cancer is divided into III A
(potentially resectable) and IIIB
(unresectable) subgroups (7).

Although most patients with Stage IIIA

disease will ultimately not be
candidates for resection based on
tumor extent and/or clinical grounds
(general health, lung function
etc.)(3,8), some carefully selected
patients will be able to undergo total
resection of gross cancer. This results
in a better survival for Stage IIIA
patients as a group when compared
with Stage IIIB patients (7,9), who are
all unresectable.

This paper analyzes our results for
treating a selected group of
unresectable Stage III (IIIA & IIIB)
lung cancer patients with aggressive
irradiation alone.

Methods and materials

A total of 378 patients with a
diagnosis of lung cancer (both small
and non-small cell, all stages) were
seen in the Department of Radiation
Oncology at vVu in Charleston from
1/1/84 - 1/1/87. Of these patients, 112
were individuals with previously
untreated Stage III NSCLC. From this
group, those who met the following
criteria were selected for our study:

a) no supraclavicular adenopathy;

b) no pleural effusion; c) aggressive
(< 5,000 rad) radiation treatment; d) at
least a fair (Karnofsky > 60)
performance status; and e) no
chemotherapy before, after or during
radiation.

After these exclusions, 50 Stage III
patients remained and we utilized
these individuals for our study
because we felt they would have a
reasonable chance for extended
survival when treated only with
aggressive irradiation. Charts were
reviewed in July 1989 and the status
of the surviving patients was updated
December 1, 1990. Survival curves
were calculated from the date of
diagnosis using the Kaplan-Meier
Method. Differences in survival at
specific times were compared for
statistical significance by the Chi-
Square test. Minimum follow-up was
four years.

All patients in this study received at
least 5,000 rad (range 5,000-8,500,
median 5,500). Daily radiation doses
varied from 150 to 400 rad, with most
patients receiving 250 rad-300 rad per
day. All but two of these patients
were given a two to three week break
midway through treatment.

Forty patients (80%) were treated
with a posterior spinal cord block
throughout their second half of
therapy as a means of keeping the
spinal cord dose within acceptable

JANUARY 1994, VOL. 90 9

Table 4. Characteristics of Potentially Cured Patients

Patient

Histology

TNM„

How T was
Determined

Stage

Dose (rad)

DFS

PD Large Cell

T„N„

Thoracotomy

IIIB

6000

6 yrs

PD SCC

t4n0

Bronchoscopy

IIIB

6500

5 yrs 1 mo

WD SCC

t3n0

Chest Xray

IIIA

5000

6 yrs 2 mo

Abbreviations: FD — Poorly Differentiated, WD = Well Differentiated, SCC = Squamous Cell Carcinoma, DFS = Disease Free Survival.

Fig. 1. Survival for the Group (50 Patients)

(n= Number of Patients Alive)

limits. This was accomplished in the
other 10 patients by use of oblique
fields or excluding the mediastinum
from the radiation field during the
second half of therapy.

Results

The 50 patients in our study
included 37 males and 13 females
with a median age of 67 years. Degree
of tumor differentiation was specified
in 37 patients and 70% of these were
poorly differentiated tumors. Table 2
shows the patient distribution by TN
classification and stage subgrouping.
Twenty-one patients were node
positive and all but two of them had
N2 disease.

Figure 1 shows survival for the

entire group. Median survival was 10
months, and one, two, three and five-
year survival rates were 42%, 20%, 8%,
and 6% respectively.

Table 2 reveals that 28 patients had
Stage IIIA disease and 22 patients had
Stage IIIB disease. Survival curves for
these two groups of patients are
shown in Figure 2. At 12 and 18
months, survival was approximately
18% better for Stage IIIA patients, but
this was not statistically significant
(Table 3). At two years and beyond,
the survival curves were essentially
identical with approximately 5% of
both Stage IIIA and Stage IIIB patients
alive and cancer free at five years.

Three patients were alive and
cancer free at the time of analysis. All

had survived more than five years
since diagnosis and are potentially
cured (Table 4). Note that all three
were node negative. In contrast, only
one node positive patient (T3N2)
survived more than three years.

A total of 32 of our patients could
be evaluated for their initial site of
cancer recurrence. Local (within the
radiation field) failure only was the
initial site of cancer recurrence for 15
patients (47%). For specific histologies,
50% of squamous cell carcinomas and
38% of adeno/large cell carcinomas
initially had local failure only as the
first site of recurrence.

Discussion

This paper analyzed the results of
treating a selected group of patients
with unresectable Stage III ( locally
advanced non-metastatic) lung cancer
with irradiation alone. Since the
overall prognosis for these patients is
poor, we selected a subgroup that had
prognostic factors associated with
improved survival (1) in order to
evaluate the results of radiation
treatment given in optimal
circumstances. Good performance
status and weight loss less than 5%
are two factors that have consistent!
been shown to double median
survival when compared to similar
staged patients without these
favorable factors (1,5,6). We had
hoped to include only patients with
these characteristics in our study, but~ i
our data was not detailed enough for
us to do this. Alternatively, we were
able to identify and exclude patients
with a poor performance status
(Kamofsky < 50), pleural effusion,
supraclavicular nodes, and radiation
dose < 5,000 rad. We felt that these
exclusions would yield a group of
patients with a reasonable chance for
long-term survival when treated by
aggressive irradiation. Fifty patients
met this criteria and formed the basis
for our study.

Our patients achieved 1, 2, and
5-year survival rates of 42%, 20%, and
6% respectively (Figure 1). This is
similar to what is reported in the
literature (1,4, 5, 6) and emphasizes the
fact that radiation alone will produce
significant one and two-year survival
rates for selected patients with Stage
III lung cancer. In addition,
approximately 5% of patients will be
cancer free and potentially cured, five 1
years after treatment with radiation.
Consequently, it is our opinion that

10 THE WEST VIRGINIA MEDICAL JOURNAL

Fig. 2. Survival. Stage IIIA vs Stage IIIB

withholding radiation treatment for
asymptomatic Stage III lung cancer
patients solely on the grounds that
they are incurable is not valid.

Three of our patients were cancer
free more than five years after
diagnosis (Table 4). All of these patients
were node negative. A posterior spinal
ord block was used on most of our
itients throughout their second half
therapy. At the time, this was an
cepted and commonly-used
uatment technique to keep the
diation dose to the spinal cord within
:eptable levels. However, it also
creases the dose to the mediastinal
odes.

We feel that this decreased
lediastinal dose, at least in part,
ccounts for the fact that none of our
patients with nodal involvement were
5-year survivors, and only one patient
with nodal involvement lived more
than three years. Other reports have
shown that a small percentage of
patients with mediastinal node
involvement will be free of disease
five years after treatment with
irradiation (4,5). Techniques for keeping
the dose to the spinal cord within
acceptable limits without decreasing
the dose to the mediastinal nodes have
been standard practice in the
Department of Radiation Oncology at
WVU in Charleston since 1988.

Stage III lung cancer is subdivided
into IIIA (potentially resectable) and
IIIB (unresectable) subgroups (7,9).

Our data (Figure 2) showed no
statistically significant difference in
survival for patients with Stage IIIA
and IIIB disease treated with radiation
alone. A similar, but much larger study
from the University of Pennslyvania
(6) also found no difference in
survival for Stage IIIA and IIIB

patients treated with irradiation.

Based on these initial studies, it
would appear that irradiation yields
equivalent survival rates for Stage IIIA
and IIIB patients. This is not
surprising since the subdivision of
Stage III lung cancer was based
entirely on surgical resectability.
However, additional studies wil be
needed before this finding can be
accepted or rejected.

Although recurrence within the
radiation field is more common for
squamous cell than it is for adeno or
large cell carcinoma (1,4), control of
the primary tumor continues to be a
major problem for all histologies
when Stage III lung cancer is treated
with irradiation. With a median dose
of 5,500 rad, the primary tumor site
alone was the initial site of failure for
47% of our evaluable patients. In the
University of Pennsylvania study,
Curran and colleagues (6) reported
that with a median dose of 5,900 rad,
the primary tumor site was the first
site of failure for 45% of their patients.
For Stage IIIA patients receiving 6,000
rad, Perez (4) reports that local failure
was a component of the initial site of
relapse in 40% of patients.

With 40%-55% of patients initially
failing in the radiation field (1,4,6), it
would seem that better local tumor
control would translate into improved
survival rates. In hopes of achieving
this, a study has been instituted with
patients receiving radiation twice,
rather than the usual once per day.
This treatment technique allows
delivery of higher radiation doses than
can be delivered with standard once
daily treatment. Preliminary results
from this study are encouraging with
20% of Stage IIIA (all N2) patients
disease free at three years as compared

to 7% of similar patients treated in
standard one treatment per day
fashion (5).

Due to the high propensity for
patients with Stage III lung cancers to
develop distant metastasis, improved
local control will, most likely, provide
only modest gains in survival rates.
Significant improvement in survival
rates will only occur when effective
systemic therapy is developed.
Unfortunately, chemotherapy has
shown only minimal benefit for non-
small cell lung cancer (1). Current
protocols are combining radiation with
chemotherapy hoping to obtain a
synergistric effect on survival rates for
patients with Stage III disease.

Summary

Approximately 1/3 of non-small cell
lung cancer (NSCLC) patients present
with locally advanced, non-metastatic
disease (Stage III). Based on resectability,
Stage III disease is divided into Stage
IIIA (potentially resectable) and Stage
IIIB (unresectable) subgroups.

Most patients with IIIA disease turn
out to be unresectable and all patients
with IIIB disease are unresectable.
Standard treatment for unresectable
patients is radiation therapy. Based on
initial data, it appears that survival
rates for patients with Stage IIIA or
Stage IIIB disease are similar when
treated with irradiation.

Radiation treatment alone can be
expected to yield one and two year
survival rates of 40% and 20%
respectively for Stage III NSCLC
patients. Although overall prognosis
remains poor for this group of patients,
approximately 5% of selected patients
with Stage III disease will be cancer
free and potentially cured, five years
after treatment with irradiation.
Consequently, we feel that
withholding radiation treatment for
asymptomatic Stage III (NSCLC)
patients solely on the grounds that they
are incurable is not valid.

Recurrence within the radiation
field continues to be a major problem
for patients with Stage III NSCLC,
accounting for the initial site of failure
in 40%-55% of patients. Improvements
in local control will likely improve
survival rates somewhat, but, because
of the marked propensity for these
cancers to ultimately develop metastatic
disease, significant improvement in
survival rates will only occur when
effective systemic therapy is available.
Unfortunately, none exists at this time.

JANUARY 1994, VOL. 90 11

Acknowledgements

The authors would like to thank Mr.
D. L. Hanshew, J. L. Zhang, Ph.D.,
and S. M. Magnetti, Dr. PH, of the
Medical Research Services of
Charleston Area Medical Center for
their assistance in our graphic display
and statistical analysis. The authors
would also like to thank Ms. Sandy
Loyd for her excellent secretarial
assistance and patience throughout
this project.

References

1. Minna JD, Pass H, Glatstein E, Ihde DC.
Cancer of the lung. In: DeVita VT Jr,

Heilman S, Rosenberg SA editors. Cancer -
principles and practice of oncology.
Philadelphia: J.B. Lippincott, 1989:590-705.

2. Boring CC, Squires TS, Tong T. Cancer
statistics, 1992. CA-A Cancer Journal for
Physicians 1992:42C 1): 19-38.

3- Burt M, Martini N. Surgical treatment of lung
cancer. In: Baue AE, Geha AS, Hammond
GL, et al., editors. Glenn’s thoracic and
cardiovascular surgery. Norwalk: Appleton &
Lange, 1991:355-73.

4. Perez CA, Pajak TF, Rubin P, et al. Long-term
observations of the patterns of failure in
patients with unresectable non-oat cell
carcinoma of the lung treated with definitive
radiotherapy: Report by the Radiation
Therapy Oncology Group. Cancer 1987-
59:1874-81.

5. Cox JD, Azamia N, Byhardt RW, et al. N>
(Clinical) non-small cell carcinoma of the
lung: prospective trials of radiation therapy
with total doses 60 Gy by the radiation
therapy oncology group. Int J Radiat Oncol
Biol Phys 1991;20:7-12.

6. Curran WJ, Stafford PM. Lack of apparent
difference in outcome between clinically
staged IILA and IIIB non-small cell lung j
cancer treated with radiation therapy I Clin !
Oncol 1990; 8:409-15.

7. Mountain CF. A new international staging
system for lung cancer. Chest 1986;89:

(suppl) 225-233.

8. Shields TW. The significance of ipsilateral
mediastinal lymph node metastasis (N2
disease) in non-small cell carcinoma of the
lung. J. Thorac Cardiovasc Surg 1990;99:48-
53.

9. Mountain CF. Value of the new TNM staging

system for lung cancer. Chest 1989; 96 1

(suppl) :47-9-

MARK YOUR CALENDAR

Charleston Area Medical Center
Presents

Advanced Trauma Life Support Course (ATLS)

Saturday-Sunday, February 26-27, 1994
— /

Program Director:

James W. Kessel, M.D.

Medical Director - Trauma Services
Charleston Area Medical Center

Location:

Charleston Area Medical Center
Education & Training Center
Charleston, West Virginia

For More Information:

For additional information, please contact the CAMC - Continuing Education
and Conference Services Department - 348-9581.

12 THE WEST VIRGINIA MEDICAL JOURNAL

Serum ferritin and myocardial infarct

GUNTHER H. FREY, M.D.

Professor Emeritus of Medical Sciences,
Concord College, Athens, W. Va.

DANIEL W. KRIDER, PH D.

Professor and Chairman of the Department of
Mathematics, Concord College, Athens, W. Va.

Abstract

In a recent Finnish study, an
association of high serum ferritin
levels with excess risk of
myocardial infarction in men was
reported. This was the first such
report in the literature so we
decided to review the clinical
records of 298 male patient seen
over a 10-year period in Southern
7est Virginia, in whom serum
erritin levels were obtained Of the
32 patients who experienced an
acute myocardial infarction, there
were no significant statistical
differences between their mean
ferritin levels and the ferritin levels
of the 266 patients with no
myocardial infarct. Only two of the
32 patients with myocardial infarct
showed an elevated serum ferritin
level, so our findings do not support
the hypothesis that high serum
ferritin levels are associated with
myocardial infarct.

Introduction

In a recent issue of Circulation ,
there appeared a clinical study report
by Salonen et al, entitled: “High stored
iron levels are associated with excess
risk of myocardial infarction in Eastern
Finnish men” (1). The investigators
from the Research Institute of Public
Health, University of Kuopio, Finland,
concluded that the results of their
prospective study suggested that a
high ferritin level is a risk factor for
coronary heart disease.

Their study population consisted of
1,931 normal, healthy Finnish males
ages 42-60, who were followed for
five years. Of these men, 51
experienced an acute myocardial
infarct (MI) during an average follow-
up period of three years. Men with a
serum ferritin level above 200 ng/1
had a 2.24 times higher risk factor for
acute myocardial infarct than those
with serum ferritin levels below 200
ng/1.

These researchers also found a
statistical correlation between elevated
serum ferritin levels and blood
glucose, triglyceride concentration and
systolic blood pressure readings. A
sub group of 677 other males with
“prevalent coronary heart disease,” as
defined by a history of previous MI or
angina pectoris, were excluded from
their analysis.

This interesting report, which
appeared to be the first of its kind
linking high ferritin levels to
myocardial infarct in men, prompted
us to review the charts of all male
patients seen during the past 10 years
in an outpatient setting in a small rural
West Virginia community.

Methods and materials

We reviewed the charts of 298 male
patients for whom complete records
were available from a physician in
general practice. These individuals
were mainly from two Southern West
Virginia counties with a high number
of mine workers who had been
exposed to mine dust. All patients
were followed for periods from 1-10
years with a mean of 5.16 years.

Every patient had a complete
physical examination, a 12-lead
electrocardiogram; a chest X-ray; and
a chemical profile consisting of
glucose, blood urea nitrogen,
creatinine, total cholesterol,
triglycerides, calcium, phosphorus,
sodium, potassium chloride, uric acid,
total protein, albumin, globulin, and
A/G ratio, total bilirubin, alkaline
phosphatase, LDH, SGOT, SGPT, GTT,
ionized calcium, thyroid profile
(consisting of T3 uptake, T4 total, and
T7), complete blood count with

differential, leukocyte count, lipid
profile (HDL cholesterol, LDL, VLDL);
and serum ferritin levels taken at the
beginning and end of the period of
observation.

Serum ferritin was determined by
the Magic Ferritin (125) Radio-
immunoassay procedure which
employs constant amounts of two
antibodies, one covalently coupled to
paramagnetic particles and the other
radioiodinated. The normal range for
this method is 7-350 ng/1, with a mean
of 51 ng/1 for males. All myocardial
infarctions were documented by
electrocardiographic and other
evidence obtained in the office and
from hospital records.

All blood samples were obtained
while the patients were fasting. None
of these patients were taking any iron-
containing preparations, and no
information was routinely recorded
about their smoking habits.

Results

There were 298 male patients in our
study population and their clinical
diagnoses are summarized in Table 1.
Their serum ferritin levels ranged from
1 1 to 900 ng/1, with a mean of 155.9,
S.D. 63.6 (Table 2).

Acute myocardial infarction
occurred in 32 of the 298 patients
during the period of observation; and
four of these were fatal. There was no
significant statistical differences
between the mean serum ferritin level
of the 32 patients with myocardial
infarct and the 266 patients with no
myocardial infarct (P = 0.23). Only
two (or 6.3%) of the 32 patients with
myocardial infarct had a serum ferritin
level exceeding 200 ng/1, i.e. 262 and

TABLE 1. Multiple Diagnoses of 298 Male Patients Seen By a General Practitioner in
Southern West Virginia

Chronic obstructive lung disease

162

Valvular heart disease

Hypertension

Nephrolithiasis

Coronary insufficiency/ Angina

Diverticulosis

Peptic ulcer/Reflux

Hyper/Hypothyroidism

Arthritis

Stroke

Hyperlipidemia

Seizure disorder

Acute myocardial infarction

Hernia

Diabetes

Psoriasis

Lumbosacral spine syndrome

Gout

Peripheral vascular disease

Aneurysm

Cardiac arrhythmia

Osteoporosis

Alcoholism

Alzheimer’s disease

Prostatic hypertrophy

Gilbert’s Syndrome

Carcinoma

JANUARY 1994, VOL. 90 13

Table 2. Ferritin Levels

Number of Patients Mean Ferritin Level St. Dev. Range

All males
M.I.

No M.I.

298

155.9

63.6

11 to 990

147.8

65.0

18 to 378

266

156.9

63.5

11 to 990

No significant difference between the mean for patients with M.I. and the mean with no M.I.
(P = 0.23)

Ferritin Levels above v. below 200 n/ml

Below
200 n/ml

Above
200 n/ml

Patients with M.I.

Patients with no M.I.

223

266

253

298

Table 4. Ferritin Level by Age

Ferritin

Number of

■$

Age

Level

Observations

— J

30 - 39

172.4

40 - 49

161.7

180

50-59

157.8

154

60 - 69

151.9

133

70 - 79

146.4

80 - 89

119.0

Age

Table 5.
Ferritin

Ferritin Levels — All Observations
Number of Observations

N = 600

Ferritin

Percent of Observations

Level

No M.I.

M.I.

Level

No M.I.

M.I.

0- 99

107

0- 99

19.1

20.5

100 - 199

351

100 - 199

62.6

69.2

200 - 299

14.4

5.1

300 - 399

2.7

5.1

400 - 499

0.7

0.0

500 - 599

0.5

0.0

600 - 699

0.0

700 - 799

0.0

800 - 899

0.2

0.0

900 - 999

0.2

0.0

Ferritin Level by Age

Ferritin level

Table 3. Comparison of Initial and
Final Ferritin Levels

Number Mean St. Dev.

Initial 297* 159.8 46.6

Final 297 153-6 111.7

Difference 297 6.21** 116.7

* One patient with fatal M.I. had only-
one observation

** No significant difference (P = 0.48)

378 ng/1 respectively. This contrasts
with 43 (or 16.2%) of the patients who
did not experience a myocardial
infarct (Table 2).

There was no significant differenc
between initial and final serum ferri
levels (Table 3). In addition, Table 4
shows ferritin levels by age groups
and the level decreases with age, as
observed in other limited population
studies (1,3, 4, 5).

Table 5 compares ferritin levels in
the two groups of patients. The small
differences observed were not
statistically significant.

nivo

subj1

leve

B’

pal®

leve

and

sen

®v

S.D

ng'1

: Sig!
grc

I n

Statistical method

Student’s t-tests for large samples
were used to test for differences
between means, and the Pearson
product-moment correlation
coefficient was used to compare
variables. All P-values shown are for
one-tail tests.

A single ferritin level was assigned
to each patient for the purpose of
comparing the ferritin level of patients
who experienced myocardial
infarction with the ferritin level of
those who did not experience
myocardial infarction. The mean of all
observed ferritin levels for a single
patient was assigned to those 266
patients who did not experience
myocardial infarction. For the 32
patients who experienced myocardial
infarction, the mean of only the
ferritin levels observed at time of the
episode was assigned.

Discussion

Analysis of our data shows some
dramatic differences from those
reported by Salonen and colleagues.

For example, in the Finnish study,
the mean serum ferritin level for 1,931
subjects was 166 ng/1, with a S.D. of
149 and a range of 10-2270 ng/1. The
mean serum ferritin level for the 51
subjects who developed myocardial
infarction were significantly higher
than that (exact numbers were not
given). The Finnish researchers also
found a 2.2-fold increase risk for

14 THE WEST VIRGINIA MEDICAL JOURNAL

Inyocardial infarct among their
subjects with elevated serum ferritin
levels above 200 ng/1.

By comparison, our data for all 298
patients showed a mean serum ferritin
level of 155-9 ng/1, with a S.D. of 63. 6,
and a range of 10-900 ng/1. The mean
serum ferritin level of 32 patients with
myocardial infarct was 147.8 with a

S.D. of 63-5 and a range of 50.5-378
ng/1. There was no statistically
significant difference between the two
groups, (P = 0.23).

It is also interesting to compare our
mean serum ferritin levels with those
vailable from limited population
tudies in the literature. Herbert (2)
eported that the average American
aale, ages 18 to 64 years, has a serum
.erritin level of about 80 ng/1.

Lipschitz et al. (3) found the mean
male plasma ferritin level to be 100
ng/1 with a S.D. of 60. Cook et al. (4)

reported the median serum ferritin
level in the State of Washington for
1,564 males ages 18-45 to be 94 ng/1.
Johnson et al. (5), in an Icelandic
random population study of 925 males
ages 25-74, found a mean level of 198
ng/1.

We conclude that we have been
unable to confirm an association
between high serum ferritin levels and
the occurrence of myocardial
infarction.

Conclusion

A retrospective analysis of the
clinical data of 298 male patients,
followed over a period of up to 10
years, failed to show any correlation
between high serum ferritin levels and
acute myocardial infarct. Admittedly,
both the Finnish prospective study in
healthy males and this retrospective

analysis in outpatients represent only
small pilot studies.

Large scale clinical evaluations are
needed to provide further evidence of
any possible association between
serum ferritin levels and coronary
heart disease.

References

1. Salonen J, et al. High stored iron levels are
associated with excess risk of myocardial
infarction in Eastern Finnish men.
Circulation 1992;86:803-11.

2. Herbert, V. Prevalence of abnormalities of
iron metabolism in the USA. Serum ferritin
(technical monograph). National Health
Laboratories.

3. Lipschitz, DA, et al. A clinical evaluation of
serum ferritin as an index of iron stores. N
Eng J Med 1974;290:1213-6.

4. Cook, JD, et al. Estimates of iron sufficiency
in the U.S. population. Blood 1986;68:726-
31.

5. Johnson et al. Prevalence of iron deficiency
and iron overload in the adult Icelandic
population. J Clin Epidemiol 1991;44:1289-97.

Manuscript Guidelines

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more than 25 references will be published free of charge.

6. Tables

7. Legends for illustrations

All persons designated as authors should qualify for
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Where reference is made to generically-designated drugs,
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All scientific material is reviewed by the Publication
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Medical Journal, P.O. Box 4106, Charleston, WV 25364.

JANUARY 1994, VOL. 90 15

President's Page

M-~b

When a reporter calls,
call back!

Communicating with the media can be both a rewarding
and a frustrating experience. Both the reporter and
physician are under significant pressures of time to get
their jobs accomplished. It is important though, that we as
physicians, realize the deadline pressures reporters are
under and always give them the courtesy of a response as
quickly as possible.

Unfortunately, as a profession, it appears that we fail to
show the news media the proper respect by not returning
their phones calls. This fact was brought to my attention
recently after reading a letter which Therese S. Cox, the
medical reporter for the Charleston Daily Mail, wrote to
the editor of the Journal Dr. Stephen Ward. This letter is
printed on the opposite page and I hope each of you take
the time to read it because Ms. Cox’s comments provide a
valuable insight into the difficulties reporters face when
dealing with physicians.

In her letter, Ms. Cox poses a question which shows just
how frustrating it is for reporters to try to interview
physicians — “How can I responsibly communicate
doctors’ words to the public when they won’t call back?”
We obviously need to make drastic changes in the way we
interact with the media because improving our
communication and trust can only help to improve our
public image.

There have been problems between the news media
and physicians for years, and a recent study by the
Freedom Forum First Amendment Center at Vanderbilt
University written by Dr. Harrison L. Rogers, a past
president of the AMA, and Rita Rubin, former medical
reporter for the Dallas Morning News, revealed just how

extreme this communications gap has become. The study
stated “To the positive points raised by one side, there are
negative responses from the other. Doctors don’t trust the
news media; the news media don't trust doctors. Our
research suggests that on no other newsroom beat —
including business, where the disenchantment is
palpable — is there such an atmosphere of mutual mistrust.”
The study made recommendations to journalists, to
doctors and to academic institutions about how to improve
relations between the media and physicians. The
recommendations to doctors are as follows:

* Physicians and researchers should be as accessible to
the press as their schedules allow, keeping reporters’
deadlines in mind.

* Doctors who expect to have contact with the press
should seek training in order to better understand
reporters’ needs and constraints.

* Physicians should discuss ground rules concerning
on/off-the-record comments and the right to review
quotes before, not after, interviews begin.

* Medical researchers presenting papers at scientific
meetings should discuss their presentations with
reporters.

* If reporters don’t get medical stories right, physicians
should let them know. If corrections are not
forthcoming, physicians should let the public know.

I hope each of you will take these suggestions seriously
and do your part to improve media relations. So, next time
a reporter calls, call back!

James L. Comerci, M.D.

16 THE WEST VIRGINIA MEDICAL JOURNAL

Editorial

A special message about media relations

Stephen D. Ward, M.D.

Chairman, Publication Committee
West Virginia Medical Journal
4307 MacCorkle Avenue, S.E.

Charleston, WV 25304

Editor:

I write about health for the Charleston Daily Mail newspaper.

I respect and often seek the advice and opinions of your colleagues. What better way is there to educate
our readers on health issues?

However, the exercise of reaching physicians on the phone can be fraught with frustration.

I realize they are quite busy. But deadlines are a fact of journalism. How can I responsibly communicate
doctors’ words to the public when they won't call back? Readers would be so much better informed if I
could include the comments of a respected physician, whether the story was of the news or feature variety.
A call back would be most appreciated.

By the way, these comments do not apply across the board. A few Charleston physicians have been very
accommodating. And your president, Dr. James Comerci, always shows utmost consideration.

Thank-you.

Warmly,

Therese S. Cox

Dear Ms. Cox:

Doctors are really timid souls, easily frightened, particularly by reporters and prone to a form of late
onset stage fright (perhaps a slow virus) brought on by seeing their name in print. Once inoculated by the
virus, however, they seem to recover with lifelong immunity but occasionally with an unfortunate lifelong
compulsion to write letters to the editor.

I suffer from a particularly virulent form of this strange compulsion.

Best regards,

Stephen D. Ward, M.D.

Editor

( Please see Dr. ComercVs message on the opposite page about the importance of
interacting with the media.)

JANUARY 1994, VOL. 90 17

In My Opinion

Clinton’s health care plan deserves praise,
much criticism

In President Clinton’s health reform
plan, there are some points to
praise but much to condemn. First, he
deserves praise just for tackling this
complex subject. The 1,342 page bill
now before Congress attests to its
complexity; before the election, he felt
it would take just nine hours of his
time to reform health care.

Secondly, I think President Clinton
is right on the matter of employer
mandates, even though most of my
colleagues on the Legislative
Committee of the WVSMA oppose this.
They feel it is an unwarranted
intrusion into the employer-employee
relationship, and while that is true for
a purist in the 18th century, the same
can be said of the minimum-wage
laws and all other features of labor
law.

I feel employee mandates are right
for the following reasons:

1 . It is a uniquely American
solution. Tying health insurance to
employers began after WWII, as
benefits were fully deductible, and not
taxable to the employer. European,
Japanese, and Canadian patients look
to their governments, not their
employers.

2. Workers comprise 34% of the
uninsured, and an additional 27%

(81% total) are dependents of
workers. Having some employers
provide benefits, while others do not,
creates unfair competition, favoring
the irresponsible.

3- The system has been tried in
Hawaii for over 20 years, and it works
there by keeping the uninsured to
about 3%. Businesses in Hawaii
cannot escape over the borders, and
to be effective, the plan must be
national in scope, not state-by-state.

4. Though some prices will rise, the
effects will be uniform across an
industry, and no one will gain an
advantage by short-changing his/her
employees.

The third point I agree with the

president about is phasing out
Workers’ Compensation and the
health insurance part of automobile
insurance. A broken leg is a broken
leg, whether you get it skiing,
working, or in an automobile
accident. The treatment is the same,
and if all are covered, there is no need
for these duplicative programs.

The last item the president is right
about is universal coverage. This is
perhaps the major issue on which the
president and the medical profession
agree — that every patient should have
access to medical care. He has
indicated that it is the only non-
negotiable point of his program.

Where, then, is the disagreement?
The plan is so complex, so radical in
restructuring, and so bureaucratic in
nature that it throws out the baby with
the bath water, destroying the good as
well as the bad.

To begin, consider the National
Health Board. It is set up above the
laws. When they set fees or spending
caps, there is no possibility of
congressional or judicial review. Who
wrote this - Joseph Stalin? The
president and the Congress are not
above the law; why should the
National Health Board be? All that is
required of a deity is that they be
omnipotent, omnipresent, omniscient,
and possessing eternal life, and these
are granted. Perhaps deification will
await a second term since it’s so hard
to get through Congress.

Secondly, large bureaucracies
(health alliances) are created. The
author of "Managed Competition ” is
Alan Einthoven. He envisioned health
alliances as being associations of
smaller businesses, pooling their
purchasing power. He never envisioned
them as governmental agencies,
setting prices and fees and dictating to
providers. Like Frankenstein, he now
disclaims and opposes what he played
a role in creating, because, as an
economist, he recognizes that price
controls have a 4,000 year history of

failure, producing only shortages,
rationing, black markets and
destruction of the market.

The third criticism I have with the
plan is the fact that solo practice
seems an endangered species. Large
networks seem the order of the day.
Germany, England, Canada and Japan
have not found it necessary to ban
solo practice; the Soviet Union did. Is
this the model? Even the Congressional
Budget Office admits that there is no
proof that “Managed Care” saves a
dime. If not, why force all practitioners
into this pattern? President Clinton
pays only lip service to abolition of
the micromanagement of insurance
companies, but replaces it with a
worse system of micromanagement by
bureaucrats whose only yardstick is
the annual cost.

Another problem with the plan is
that it will worsen the practice of
medicine by requiring that 50% of
practitioners be primary care
physicians who will care for almost all
conditions. OB-GYN physicians have
lobbied to be considered primary care
physicians, and have won this
concession. They are, for many
women, the only physician they see.
But, when the woman who sees her
OB-GYN physician has a myocardial
infarction, the guidelines will mandate
that the OB-GYN physician takes
primary responsibility unless
complications arise.

My fifth objection is that the plan
makes no provision for advances in
medical science. When an AIDS
vaccine appears, it would be given to
a large number of people, and be
temporarily inflationary. No more; if it
be given it must displace something
else, such as DPT immunization, or
polio, in order not to be inflationary.

Senator Rockefeller has criticized us
for tepid support of the bill. He wants
zealots, voting yes for every one of
the 1,342 pages, no matter how
offensive, or wrong. There is no
Hippocratic Oath to participate in the

18 THE WEST VIRGINIA MEDICAL JOURNAL

destruction of a proud profession with
3-4 millennia of honorable service to
nankind. I used to rail at the agencies
;hat sent me letters “Dear Provider.”
‘I’m not a provider, damn it. I'm a
physician, a doctor.” If the Clinton bill
passes, I’ll have to say, “I'm not a
doctor — I’m just a provider.”

I'm not defending the status quo
because in many instances the status
quo stinks, particularly in the role of
the health insurance companies. We
desperately need health insurance
reform to reform the cherry-picking,
the absolute risk avoidance, to make
policies portable, to eliminate the
exclusion of prior conditions, and the
irrational rating of totally benign
disorders. But, we must build on the
strength of our present system — the
dedication and professionalism of the
medical profession and ancillaries, the
finest system in the world for
provision of care, and seek to
improve only the problem areas. We

must restore market forces to medical
care through medical IRAs (proven to
work in Singapore, whereas, the
president’s plan is completely untried
and unproven).

A sixth issue I feel must be
challenged is the matter of privacy. To
enlarge support for the bill, privacy
issues are submerged for the first few
years. As a consequence, sensitive
medical data will be protected only
after being widely distributed. Your
sexual preferences, fears, fantasies,
defecatory practices, partners, and
diseases will all be public knowledge
before they are protected.

Funding for this bill is my major
concern. To believe the president’s
figures, you have to first believe in the
Tooth Fairy, the Easter Bunny and
Santa Claus as major funding sources.
If you can do that, you can envision
an extra 37 million people insured,
expanded benefits, and no new taxes
unless you are addicted to cigarettes.

Money will be taken from Medicaid
and Medicare as well. No matter that
hospitals are already losing billions on
these programs now, and are only
existing because of cost-shifting. Every
dollar sucked from these programs
will only increase the loss, and since
cost-shifting will be eliminated,
bankruptcies will follow.

This is no time for the summer
soldier and the sunshine patriot. We
are under seige, and we must man the
ramparts. We should not be afraid to
speak up on these matters in which
we, not the politicians, are the
experts. We should seek to modify
the bill, keeping in mind our single
mission to save our patients’ health. If
it is not possible to modify the bill, we
should commit to the defeat of the
bill, our lives, our fortunes, our sacred
honor.

Wallace D. Johnson, M.D.

Beckley, WV

Hjou axe aoxcLialtij invited to attend, tfie

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laxy 14, 1994

tBiufing: 3:30 - 5:30 fi.ni.
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925-O34Z

JANUARY 1994, VOL. 90 19

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At Mid-Winter

Third Session to feature topics on environmental
medicine, patient communication issues

Since the public views physicians as
the most trusted source of information
regarding environmental health issues,
this year’s Third Scientific Session at
the WVSMA’s Mid-Winter Clinical
Conference at Lakeview Resort and
Conference Center in Morgantown is
entitled “Symposium on Environmental
Medicine and Patient Communication. ”

Set for Saturday, January 22 at 2 p.m.,
this Third Scientific Session is being co-
sponsored by the WVSMA and the
National Institute for Chemical Studies
in Charleston (NICS). The moderator
for this symposium will be Susan L.
Santos, M.S., research program director
of the Columbia University Center for
Risk Communication in New York City,
who is also the principal and owner of
an environmental consulting firm called
Focus Group.

This session will begin with a
presentation on "The Physician as a
Source of Environmental Information
for Patients and Communities" by Ms.
Santos and David B. McCallum, Ph.D.,
principal of the Washington, D.C.
branch of Focus Group. Following this
first segment of the program, John D.
Spengler, Ph.D., a professor of
environmental health sciences and
director of the Exposure Assessment
and Engineering Program at Harvard
University’s School of Public Health,
and Gregory R. Wagner, M.D., director
of the Division of Respiratory Disease
Studies for the U.S. National Institute
for Occupational Safety and Health in
Morgantown, will discuss “Acute and
Chronic Effects of Environmental
Exposure to VOCs in the Kanawha
Valley. ”

After a short break, the meeting will
convene with a lecture on the subject
of “Community Implications of
Environmental Exposures and
Information: A Physician ’s Perspective”
by Mary F. McDaniel, M.D., manager of
Environmental and Community
Medicine for Unocal Corporation in Los
Angeles. The final panelist for the
symposium will be Alan Ducatman,
M.D., a professor of medicine and

Santos Wagner

director of the Institute of Environmental
Health at the West Virginia University
School of Medicine. Dr. Ducatman will
talk about “Environmental and
Occupational Health Issues Facing
Physicians , ” and then a question and
answer session is scheduled with all
the panelists.

Brief biographical information about
these speakers begins below. If you

have not yet registered for the
WVSMA’s Mid Winter Clinical
Conference, you may phone in
your reservation by calling the
WVSMA at (304) 925-0342 by noon
on Wednesday, January 19, or you
may register at the door.

Lecturers highlighted

Ms. Santos provides consultation
in the areas of risk communication
and assessment in her current roles
as research program director for
Columbia University’s Center for Risk
Communication, and as the principal
and owner of the firm Focus Group,
based in Medford, Mass.

Prior to her appointment at
Columbia and starting Focus Group,
Ms. Santos was corporate director for
Risk Assessment Services with ABB
Environmental. She has over 15 years
of environmental experience in the
public and private sectors including
over eight years at EPA Region I,
primarily in the areas of toxic chemical
and hazardous waste management.

A specialist in the design,
implementation, and evaluation of
risk and environmental issue-oriented
information and education programs,

McDaniel Ducatman

Ms. Santos has developed communication
strategies for hazardous waste sites,
impact assessments, and community
and worker right-to-know programs.
She has planned and participated as a
risk communication practitioner in
nearly 200 public meetings, hearings,
citizen briefings and workshops on
behalf of government and industry.

Mrs. Santos received her undergraduate
degree in chemistry and sociology at
Boston College and her graduate
degree in civil engineering and public
health from Tufts University, where she
is currently an instructor in the
Hazardous Materials Management M.S.
Program. She has written numerous
publications about risk communication
and assessment, including a report
entitled “Comparative Study of Risk
Assessment and Risk Communication
Practices between Western Europe and
the United States , ” for which she
received a Gennan Marshall Fund
Fellowship Award in 1989-

Dr. McCallum received a B.S. degree
in chemical engineering from North
Carolina State University in 1967, an
M.S. degree in chemical engineering
from the University of Virginia in 1970,
and a Ph D. degree in biomedical
engineering from the University of
Virginia in 1979- While pursuing his
doctoral degree, Dr. McCallum worked
as director of the Division of Early
Disease Detection for the South
Carolina Department of Health and
Environmental Control in Columbia,

S.C. After obtaining his degree, Dr.
McCallum assumed another role for

22 THE WEST VIRGINIA MEDICAL JOURNAL

his department as director of the
division of Chronic Disease Control.

From 1980-81, Dr. McCallum was
i urogram coordinator for the Medical
application of Research Section of the
National Heart, Lung and Blood
nstitute of the NIH in Bethesda, Md.
de then joined the faculty of
Georgetown University Medical Center
as an associate professor and director
of the Program for Risk Communication.
Dr. McCallum taught at Georgetown
until 1990, when he was named a
visiting professor of public health at
Columbia University in New York City.
In 1993, he assumed his current role at
Columbia as an adjunct professor of
public health and began acting as a
principal for the Washington, D.C.
branch of the consulting firm Focus
Group.

A reviewer for the Journal for Risk
Analysis and JAMA , Dr. McCallum is an
accomplished author who has
published extensively about health and
environmental medicine issues. During
his career, Dr. McCallum has served in
a consultative capacity for many
agencies of the federal government,
including EPA and the F.D.A.

Dr. Spengler received a B.S. degree
in physics in 1966 from the University
of Notre Dame, a Ph.D. degree in
atmospheric sciences in 1971 from the
State University of New York at
Albany, and an M.S. degree in
environmental health sciences in 1973
from Harvard University. In addition to
his current roles as a professor of
environmental health sciences and
director of the Exposure Assessment
and Engineering Program at Harvard
University’s School of Public Health,

Dr. Spengler has recently served as
either a consultant or member on
various EPA Science Advisory Board
committees.

A member of the National Academy
of Science’s Committee on Risk
Assessment of Hazardous Air
Pollutants, Dr. Spengler is also a
founding member of the International
Society of Indoor Air Quality and
Climate and the International Society of
Exposure Analysis. He was one of nine
international coordinators for the 6th
International Conference on Indoor Air
Quality and Climate held in Helsinki,
Finland in July 1993.

Dr. Spengler has conducted research
in the areas of personal monitoring, air
pollution health affects, aerosol
characterization, indoor air pollution
and air pollution meteorology, and has
published extensively about each of
these subjects. His most recent book,
co-authored with Dr. John Samet, is
entitled Indoor Air Pollution.- A Health

Perspective. He is also serving on the
editorial board for the new journal
Indoor Air.

Dr. Wagner is responsible for
conducting research, training, and
public health response activities
relevant to the prevention of
occupational respiratory diseases in his
role as director of the Division of
Respiratory Disease Studies for the U.S.
National Institute for Occupational
Safety and Health. His division also
conducts research, training, and public
health response activities relevant to
the prevention of occupational
respiratory diseases, as well as
mandated programs of surveillance for
coal miners and training for physicians
in the interpretation of X-rays for
pneumoconiosis. Under Dr. Wagner’s
guidance, NIOSH has taken the lead in
the U.S. effort to control or eradicate
silicosis.

During his career, Dr. Wagner has
been engaged in a variety of academic
and clinical activities. He taught and
practiced at the Marshall University
School of Medicine in Huntington,
where he was chief of the Division of
Occupational and Environmental Health.
Prior to this, Dr. Wagner practiced
general internal and family medicine at
the Cabin Creek Medical Center in
Davis, W.Va.

Currently involved with the World
Health Organization and the
International Labour Organization in
their efforts to establish harmonized
guidelines for screening and surveillance
of workers exposed to mineral dust, his
present professional focus is the role of
government in disease prevention. Dr.
Wagner is board certified in internal
medicine and in preventive
(occupational) medicine, and is a
certified B-reader for interpretation of X-
rays for the pneumoconioses.

Dr. McDaniel received her B.S.
degree in journalism from the University
of Tulsa in 1971, where she also
obtained her J.D. degree in 1976. After
practicing law for five years, she
attended medical school at Oklahoma
State College of Osteopathic Medicine
and received her D.O. degree in 1986.
She served an internship at St. Michael’s
Hospital in Newark, N.J., and then
returned to Oklahoma to complete a
residency in occupational medicine at
the University of Oklahoma, where she
also obtained a master’s degree in public
health in 1988.

As manager of Environmental and
Community Medicine for Unocal
Corporation, Dr. McDaniel provides
corporate support to staff and sets
strategy for company policies on
environmental health and safety. In

addition, she works as a consulting
physician for the firm Focus Group,
providing risk communication planning
and strategic intervention assistance for
companies and community groups.

Board certified in occupational and
environmental medicine, Dr. McDaniel
is a member of the American College of
Occupational and Environmental
Medicine, the Society for Risk Analysis,
the Society for Occupational and
Environmental Health and the Western
Occupational Medical Association. She is
an adjunct lecturer for the University of
California and often speaks at
community meetings regarding health
care issues.

Dr. Ducatman received an A.B.
degree in analytical biology from
Columbia College in New York in 1972
and obtained a M.Sc. degree in
environmental health from City
University of New York - Hunter College
and the Mt. Sinai School of Medicine in
1974. He then attended medical school
at Wayne State University in Detroit,
where he graduated in 1978. He
completed an internship at Brown
University in Providence, R.I., and a
medical residency and fellowship in
occupational medicine at the Mayo
Clinic.

From 1982-83, Dr. Ducatman was
director of Occupational Medical
Services for the U.S. Navy clinics at
Columbia Park and Brooklyn Park,

Minn. He then accepted another post for
the U.S. Navy as director of the
Professional Occupational Health
Branch of the U.S. Navy Environmental
Health Center in Norfolk, where he also
was an assistant professor of community
medicine at Eastern Virginia Medical
School.

In 1986, Dr. Ducatman relocated to
Cambridge, Mass., to become director of
the Environmental Medical Service at the
Massachusetts Institute of Technology.
He moved to Morgantown in 1992 to
assume his current role as director of the
Institute of Occupational and
Environmental Health at the West
Virginia University School of Medicine,
where he is also a professor of
medicine.

Dr. Ducatman is a fellow of the
American College of Occupational
Medicine and of the American College
of Physicians. He has co-authored a
book and published numerous chapters,
papers, and abstracts pertaining to
occupational health and environmental
medicine. Last year, Dr. Ducatman was
awarded the Robert J. Hilker Award by
the American College of Occupational
and Environmental Medicine.

JANUARY 1994, VOL. 90 23

At Mid- Winter

topic of Lunch and Learn

Smoak Comerci D’Alessandri

Clinton plan

As a result of the two extremely
successful Lunch and Learn programs
which were presented during the
WVSMA’s Annual Meeting last August,
another one of these events is
planned for Saturday, January 22 at
noon during the WVSMA’s Mid-Winter
Clinical Conference at Lakeview
Resort and Conference Center in
Morgantown. The topic for this Lunch
and Learn will be “President Clinton’s
Health System Reform Plan: The Pros
and Cons of the Plan and How It Will
Affect the Physician/Patient Relationship.”

The panelists for this presentation
will be AMA Trustee Dr. Randolph D.
Smoak Jr.; WVSMA President Dr.

James L. Comerci; and Dr. Robert M.
D’Alessandri, vice president for
Health Sciences and dean of the
School of Medicine at West Virginia
University. Dr. Smoak plans to discuss
the AMA’s recent decision regarding
employer mandates; Dr. Comerci will
be speaking about the managed care
concept of the president’s plan and
how managed care is currently
affecting his relationship with
patients; and Dr. D’Alessandri will be
discussing how medical schools in the
state will be affected by the drive to
increase primary care physicians, plus
the effect on the training of
specialists. The moderator for this
session will be Dr. Robert Pulliam,
WVSMA past president.

The cost for this program is $35 for
WVSMA members and other
physicians, and $20 for WVSMA
Alliance members and other guests.

Brief biographical information
about the three panelists begins
below and more information about
the Lunch and Learn can be obtained
by contacting the WVSMA at
(304) 925-0342.

Panelists highlighted

Dr. Smoak is a surgeon from
Orangeburg, S.C., who was elected to
the AMA Board of Trustees in June
1992. He served as secretary-treasurer
of the AMA Physicians Health
Foundation from 1992-93 and last
year was appointed chair of the
board’s Subcommittee on Membership.

A graduate of the Medical
University of South Carolina, Dr.

Smoak served his internship at Grady
Memorial Hospital in Atlanta and
completed his residency training at

the Medical University of South
Carolina. After completing a senior
surgical fellowship at M.D. Anderson
Hospital and Tumor Institute in
Houston, he returned to his home
state of South Carolina to establish his
surgical practice.

Elected to the South Carolina
Medical Association’s Board of
Trustees in 1972, he has served in
almost every leadership position
including president of the SCMA;
chair of the South Carolina Political
Action Committee; president of the
SCMA Members’ Insurance Trust; and
president of the South Carolina
Medical Care Foundation. Dr. Smoak
served as alternate delegate to the
AMA House of Delegates for the
SCMA in 1983, and as delegate in
1987. Since 1984, he has been on the
AMPAC Board, elected secretary in
1986 and chair in 1988.

Dr. Smoak is a founding member of
the South Carolina Oncology Society
and is a fellow and governor of the
American College of Surgeons. He is
also a diplomate of the American
Board of Surgery and an active
member of the Southeastern Surgical
Congress, the South Carolina Surgical
Society and the South Carolina
Chapter of the American College of
Surgeons. In addition, Dr. Smoak is a
clinical professor of surgery at the
Medical University of South Carolina
and a clinical associate professor of
surgery at the USC School of Medicine.

Dr. Comerci became president of
the WVSMA in August 1993- Born in
Beckley, Dr. Comerci received both
his B.A. degree in chemistry and his
doctor of medicine degree from West
Virginia University. He completed his
residency in family medicine at
Wheeling Flospital from 1980-83 and

then went into private practice in
Wheeling.

A member of the WVSMA since
1984, Dr. Comerci began serving on
Council in 1987 and was named vice
president in 1991, then president-elect
in 1992. In addition to his positions
on Council and the Executive
Committee, Dr. Comerci served as
program chairman of the WVSMA's
Annual Meeting in 1990, and has
been a member of the Legislative
Committee since 1991.

Dr. Comerci is a member of the
AMA and the Ohio County Medical
Society, of which he was president in
1990. Board certified by the American
Board of Family Practice, Dr. Comerci
is also a clinical assistant professor of
family medicine at WVU.

Very active in his local medical
community, Dr. Comerci is a board
member, a volunteer physician and a
member of the Prenatal Care
Committee at Wheeling Health Right;
is a part-time team physician at
Bethany College; and serves on the
Utilization Review Committee at Good
Shepherd Nursing Home.

Dr. D 'Alessandh is a graduate of
Fordham University and New York
Medical College, who completed his
postgraduate training at Metropolitan
Hospital in New York and the

24 THE WEST VIRGINIA MEDICAL JOURNAL

University of Florida. A specialist in
infectious diseases and general
medicine, Dr. D'Alessandri is a fellow
of the American College of Physicians
and a diplomate of the American
Board of Internal Medicine.

In his roles as vice president for
Health Sciences and dean of the
School of Medicine at West Virginia
University, he is a member of several
state and national task forces,
committees and boards. He currently
chairs the West Virginia Health Care

Reform Project convened by Governor
Caperton and Senator Rockefeller. He
served on Hillary Rodham Clinton’s
Health Care Reform Task Force and
was instrumental in organizing Mrs.
Clinton’s visit to WVU last year for the
televised “West Virginia Speaks”
health care forum.

Dr. D’Alessandri is a member of
several national medical education
groups and serves on the Executive
Committee of the Accreditation
Council for Graduate Medical

Education as a representative of the
American Association of Medical
Colleges. He was selected as the
recipient of the 1993 Medical
Executive Award of the American
College of Medical Group Administrators.

A regular guest commentator on
West Virginia Public Radio, Dr.
D'Alessandri appears each week as a
medical correspondent on WCHS-TV.
He also hosts “Doctors on Call, ” a live
public television broadcast that
answers viewers medical questions.

Neri to perform variety of 50s, 60s music at Mid-Winter

Due to popular demand after his
spectacular show at last year’s
WVSMA Mid-Winter Clinical
Conference, Dr. Florencio “Jun” Neri
will present a special musical variety
act of songs of the 1950s and 60s on
Saturday, January 22 at 8 p.m.
during the WVSMA’s Mid-Winter
Clinical Conference at Lakeview
Resort and Conference Center in
Morgantown.

Dr. Neri, a general practice
physician, is a native of the
Philippines who is well known by
his colleagues for his singing
abilities. He has performed at many
state and county medical meetings,
as well at weddings, benefit concerts
and other local events.

A 1969 medical graduate of Far
Eastern University in Manilla, Dr.

Neri did a three-year residency in
general surgery in the Philippines

Neri

before continuing his postgraduate
studies in general surgery at Long
Island Jewish Hillside Medical
Center in New York City. In 1975,
he relocated to Welch, W.Va., where

he worked at Stevens Clinic Hospital
for three years before becoming an
emergency physician at Princeton
Community Hospital.

Since 1985, Dr. Neri has been in
general practice in Princeton, where
is still affiliated with Princeton
Community Hospital. He and his
wife, Shelby, are the parents of three
children, Sheila, April and
Christopher.

In addition to Dr. Neri’s
perfonnance. Dr. Rano Bofill will be
inviting guests to sing along with the
laser-disk Karaoke machine he will
be operating. This special
entertainment is being presented in
conjunction with a reception for all
conference participants which
begins at 7 p.m. and is being hosted
by CNA Insurance Companies and
McDonough Caperton (an Acordia
Company).

WVSMA / WV-ACP

1994 Mid-Winter Seminars
and Scientific Conferences

January 20-23

Lakeview Resort and Conference Center
Morgantown, W.Va.

Phone the WVSMA at (304) 923-0342 by noon on January 19 to register

you may register at the door

JANUARY 1994, VOL. 90 25

Pharmaceutical
directory of indigent
programs published

The recently issued 1994 Directory
of Prescription Drug Indigent
Programs lists 63 separate programs
by pharmaceutical companies to make
prescription drugs available free of
charge to physicians whose patients
might not otherwise have access to
necessary medicines.

The directory, which was first
published by the Pharmaceutical
Manufacturers Association (PMA) in
1992, lists the name of each program,
the company providing it, information
on how to make a request for
assistance, the prescription medicines
covered and basic eligibility criteria.

Healthcare professionals and
patients may obtain a copy of the
updated directory by writing to
Directory of Pharmaceutical Indigent
Programs, Pharmaceutical
Manufacturers Association, 1100 15th
Street, N.W., Washington, D.C. 20005.

Snowshoe site for

cardiovascular

conference

The Cardiovascular Conference at
Snowshoe, sponsored by the
American College of Cardiology, is
scheduled for January 31 - February 2
at the Mountain Lodge Conference
Center in Snowshoe, W.Va.

A total of 15.5 CME credits in the
AMA’s Category 1 is being offered.

For information contact the
Registration Secretary, Extramural
Programs Dept., American College of
Cardiology, 9111 Old Georgetown
Rd., Bethesda, MD 20814-1699;
800-257-4739 (outside the U.S. and
Canada, 301-897-2695).

ACPM schedules
credentialing test

The American College of Pain
Medicine (ACPM) will hold its
credentialing examination in pain
medicine on February 21 at the Buena
Vista Palace in Orlando, Fla.

The examination is offered once
each year, and is open to any licensed
physician who meets the eligibility
requirements. More than 100
physicians have passed the ACPM
examination and received a certificate
designating them as specialists in the

field of pain medicine and fellows of
the American College of Pain Medicine.

For more information, contact the
ACPM office at (708) 966-0459.

Pfizer expands
efforts to dispense
free medicines

Sharing the Care: A Pharmaceutical
Access Program has recently been
announced by Pfizer, the National
Governors Association and the
National Association of Community
Health Centers. Through this program,
Pfizer will provide its most advanced,
single-source medicines to patients at
community, migrant and homeless
health centers in all 50 states who are
at or below the poverty line and are
not covered by Medicaid or any other
insurance program covering
pharmaceuticals.

This indigent care program is
expected to provide medications for
up to 1 million patients nationwide. It
will initially operate at approximately
300 eligible centers that have in-house
pharmacies. To determine the
potential for expanding the program
to all centers, demonstration projects
are also being launched in centers
that have other pharmacy
arrangements.

For more information, contact
RN Deborah Smith-Callahan at
(404) 448-6666.

New publications
available about ADA,
lymphedema pumps

ADA and the Health Professional, a
brochure which describes what health
professionals need to know about the
Americans with Disabilities Act, has
been published by the President’s
Committee on Employment of People
with Disabilities. This brochure
includes basic technical information
about the ADA, and a question and
answer section covering the
information most frequently sought by
health professionals.

To obtain a free copy, contact Ruth
E. Ross, President’s Committee on
Employment of People with
Disabilities, 1331 F St., NW, Third
Floor, Washington D.C. 20004-1107;
(202) 376-6200; (202) 376-6205 (tdd);
or (202) 376-6868 (fax).

Another free publication which has
also been recently released is a review

of lymphedema pumps printed by the
Agency for Health Care Policy and
Research (AHCPR).

Copies of this review are available
from AHCPR Publications Clearinghouse.
P.O. Box 8547, Silver Spring, MD
20907, (800) 358-9295; or from AHCPF
Instant FAX (1-301-227-0800).

State ophthalmologists
schedule national
spring meeting

The 47th Annual National Spring
Meeting of the West Virginia Academy
of Ophthalmology is set for
April 21-24 at The Greenbrier in White
Sulphur Springs.

Featured speakers will be Marshall
M. Parks, M.D., Steven A Newman,
M.D., and Frank LaPiana, M.D.

For more details, contact Pam
Stevens, West Virginia Academy of
Ophthalmology, P. O. Box 5008,
Charleston, WV 25361; (304) 343-5842
or 344-9466

Toll-free hotline
answers questions
about Rocephin®

Roche Laboratories, a division of
Hoffmann-La Roche Inc. is operating a
toll-free number (1-800-624-0264)
designed to answer questions about
reimbursement options for Rocephin®,
an injectable antibiotic used to treat a
wide variety of moderate to severe
infections.

The phone line is staffed by experts
on reimbursement issues and operates
from 9 a.m. - 5 p.m. (EST) Monday
through Friday.

Annual critical care
course set for March

The 21st Annual Critical Care
Medicine Course will be presented by
The University of Oklahoma Health
Sciences Center from March 5 - 10 at
the Marriott Hotel in Oklahoma City,
Okla.

CME credits offered will include
AMA, AAFP, AO A, ACPE.

For more details contact: Ms. Dora
Lee Smith, Course Coordinator,

OHUSC Department of Medicine,

P.O. Box 26901 - Room 3SP 400,
Oklahoma City, OK 73190,

(405) 271-5904.

26 THE WEST VIRGINIA MEDICAL JOURNAL

The West Virginia State Medical Association
& Conomikes Associates, Inc.

Present

Jan Woerth Ph.D.

MANAGED CARE

Preparing for the Clinton Health Plan

January 20, 1994

Lakeview Resort and Conference Center
Ballrooms 1+2, and lunch 3+4
Morgantown, West Virginia
9 a.m. to 4 p.m. (Lunch provided)

Workshop Outline

1. Who are the payers

• Fee-for-service variations

• Regional cooperatives and alliances

• Large companies/self-insured

• Medicare/Medicaid

• HMOs, PPOs, other managed care

2. How will you be paid

• Standard benefit packages

• Co-payment increase

• Capitation

• Fees for global services

3. Collection issues will differ

• Co-payments at time of service

• Withhold and risk pools

• Out-of-contract services

4. How certification works

• Gatekeeper function

• Treatment authorizations

• Hospital authorizations

• Referral authorizations

• Denied authorizations

5. How physicians may reorganize
their work

• Money issues

• Income distribution problems

• Group formations

• Scheduling issues

• Staffing for efficiency

6. How to look at contracts

• Key points to include

• What to watch for

• Payment issues

• Termination clauses

• "Hold harmless" provisions

7. How to track your results

Determining which plans are favorable

and unfavorable

Keeping track of your plans

Tracking withholds and risk pool utilization

For a FREE Brochure on this seminar or to register, contact Becky Campbell
at the West Virginia State Medical Association at (304) 925-0342.

Three FREE Bonuses

• Conomikes Workshop Workbook • 3-month Subscription to Conomikes
Medicare Hotline • 3-Month Subscription to Conomikes Reports

Medical Education

Continuing

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

If you would like to have the CME
programs offered by your institution or
association for physicians printed in the
Journal or obtain more details about the
meetings listed, please contact Nancy
Hill, managing editor, at 925-0342.

Robert C Byrd Health

Sciences Center of WVU - Charleston

January 20

“Teleconference on Breast Cancer
1994,” Daniel Foster, M.D., Dept, of
Surgery, CAMC

January 31-February 2

“Cardiovascular Conference at
Snowshoe” (co-sponsored by the
American College of Cardiology),
Snowshoe, W.Va.

February 3

“Ovarian Cancer Screening: When Is
It Helpful?” Fernando Recio, M.D.,
Dept, of Obstetrics and Gynecology,
HSC

Robert C Byrd Health Sciences
Center of WVU - Morgantown

February 18-20

“Primary Care Perspectives on
Women’s Health" (sponsored by the
WVU Dept, of Family Medicine),
Snowshoe Resort, Snowshoe, W.Va.

March 18 19

“AIDS in West Virginia” (sponsored
by the WVU Dept, of Medicine,
Section of Infectious Disease),
Charleston House Holiday Inn,
Charleston

West Virginia State Medical
Association - Charleston

January 20-23

WVSMA/WV-ACP 1994 Mid-Winter
Seminars and Scientific Conferences,
Lakeview Resort and Conference
Center, Morgantown

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Gassaway □ Braxton County Hospital,
Jan. 25, 6:30 p.m., “Medical
Evaluation of Sexually Abused
Children,” Kathleen Previll, M.D.

Logan □ Logan General Hospital, Jan.
21, 11:45 a.m., “Skin Cancer,” Brad
Cohen, M.D.

Man □ Man Appalachian Regional
Hospital, Jan. 19, 6:30 p.m.,
“Preventative Screening in Oncology,”
Arvind Kamthan, M.D.

Oak Hill □ Plateau Medical Center, Jan.
25, 6:30 p.m., “Blood Transfusion,”
Mary Taylor, M.D.

Parkersburg ★ Camden-Clark

Memorial Hospital, Jan. 26, 7 a.m., “Is
There a Right to Health Care?”

★ Camden-Clark Memorial Hospital, '
Feb. 9, 7 a.m., “Acute Respiratory
Failure”

★ Camden-Clark Memorial Hospital,
Feb. 16, 7 a.m., “What's New in the
Treatment of Childhood Cancer?”

★ Camden-Clark Memorial Hospital,
Feb. 23, 7 a.m., “Return to Work for
the Injured Worker: Principles and 1
Caveats”

★ Camden-Clark Memorial Hospital,
Mar. 16, 7 a.m., “Management of
Obesity”

Philippi ★ Broaddus Hospital, Feb. 3,

7 p.m., “Scoliosis/Spinal Deformity"
(Pediatrics)

★ Broaddus Hospital, Mar. 3, 7 p.m.,
“AIDS”

Point Pleasant □ Pleasant Valley
Hospital, Jan. 27, noon, TBA,
Constantino Y. Amores, M.D.

Williamson □ Williamson Appalachian
Regional Hospital, Jan. 27, 6:30 p.m.,
“Abdominal Trauma,” Bmce Hoak,
M.D.

YoiPve REACHED that certain A&E, WUCRE
EVERTtHlriS SEEMS to weak out, spread

OOT,oTZ PALL OUT »"

28 THE WEST VIRGINIA MEDICAL JOURNAL

fanuary

20-22-28th Annual Meeting of the
Neurosurgical Society of the Virginias, White
Sulphur Springs, W.Va.

20-23— WVSMA/WVACP 1994 Mid-Winter
Seminars and Scientific Conferences,
Morgantown

27-29-1 3th Annual Big Sky Pulmonary Ski
Conference (sponsored by American Lung
Association of Montana), Helena, Mont,
27-30-20th Annual Postdoctoral Education
Conference (sponsored by the Society of
Teachers and Family Medicine), Tucson,

Ariz.

27- Feb.l— American Academy of Otolaryngic
Allergy, Tampa, Fla.

28- 29-Transfusion Medicine: Update 1994
(sponsored by the American Association of
Blood Banks), Seattle, Wash,

30- Feb. 4-Westwood Winter Skin Seminar,
(sponsored by Westwood - Squibb
Pharmaceuticals), Vail, Colo,

31- Feb. 2-Cardiovascular Conference at
Snowshoe (sponsored by the American
College of Cardiology), Snowshoe, W.Va.

February

I- 5-19th Annual Meeting of the Alliance for
CME (sponsored by the George Washington
University Medical Center), San Diego, Calif.
6-10-vSoutheastem Surgical Congress, Lake
Buena Vista, Fla.

II- 12-Topics in Radiology (sponsored by
the University of Pittsburgh Medical Center),
Pittsburgh, Pa.

12-Infectious Diseases (sponsored by Ohio
State University), Columbus
18-20-1994 Annual Refresher Course and
Conference of the American Academy of
Pain Medicine, Orlando, Fla.

20-23-First International Symposium on the
Role of Soy in Preventing and Treating
Chronic Disease, Mesa, Ariz.

24-Mar. 1-American Academy of
Orthopaedic Surgeons, New Orleans, La.

26— Mar. 5-Topics in Gastroenterology and
Internal Medicine (sponsored by the George
Washington University Medical Center),
Barbados

28-Mar. 3-The Alton D. Brashear
Postgraduate Course in Head and Neck
Anatomy, Medical College of Virginia,
Virginia Commonwealth University,
Richmond, Va.

March

4-5-The 37th Annual Postgraduate
Symposium in Ophthalmology: Diagnostic
Pathology (sponsored by Ohio State
University), Columbus

For More Information . . .

Contact the Journal at (304) 925-0342.

Poetry Corner y

Group Therapy

Voices

(In the New Choir)

Unify in a grotesque cacophonous minuet
( Achapella )

Whose dissonance clangs on its own off-step noisy
Parody

Chorally
or in

Sanctioned Solo
They annotate

The threnody and lost harmony
Of individual or collective lives

The choirmaster neither directs nor sings
Yet his sonorous queries evoke a rhythm
A thin melodic line transcends the clatter
Atonality yields to hesitant richness
A refrain reverberates each time the voices sing
From fugue to resonant sinfonia

The choir is an instrument
Playing triumphantly to those in tune
Blaringly to those off-key
It is destroyed after each use
Recreated, never seems the same
Although it works the same.

Through intricate practice sessions
Symbolic serendipides
The choir
Learns words

Of songs that write themselves
To music with no score

Ralph S. Smith Jr., M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward, M.D.,
Editor, West Virginia Medical Journal. P. O. Box 4106, Charleston, WV 25364.

JANUARY 1994, VOL. 90 29

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

MJVTWR highlights
smoking concerns

The November 12 issue of the
Centers for Disease Control's Morbidity
and Mortality Weekly Report featured
several important articles on smoking
and health risks.

The report said that more physicians
and their organized medical groups are,
and should be, becoming leaders in
nationwide efforts to stop smoking
since their counseling efforts can be a
very valuable tool. The report detailed
the effectiveness of these counseling
efforts in 1991 in a report to the
National Review Interview Survey
(Health Promotion and Disease
Prevention supplement.) Cigarette
smoking remains the single most
preventable cause of premature death
in the United States.

The November 12 issue of the
MMWR also contained a report on
mortality trends for selected smoking-
related cancers and breast cancer in the
United States for the years 1950-1990.
During 1990, nearly 419,000 deaths, or
approximately 20% of all U.S. deaths,
were attributed to smoking. This
included more than 150,000 deaths
from neoplasms. The report related
that the public health burden of
smoking-related cancers will continue
throughout the next several decades. It
also examined the trends of mortality
for cancers that are significantly related
to smoking and compares lung cancer
mortality with breast cancer mortality,
which has not been linked to smoking.

For a copy of the November 12
MMWR or for more information on
smoking-related health concerns,
contact Joyce Edwards of the Bureau
of Public Health’s Tobacco Control
Program at (304) 558-0644.

Canaan Valley site for
rural health workshop

Health care providers from around
the state will meet in Canaan Valley on
February 21 and 22 for a workshop
entitled “Developing a Rural Primary
Care Network: A Hands-On Approach.”

Sponsored by several health care
organizations, the workshop will focus
on the challenges and opportunities for
communities under new health care
reform proposals, and will offer federal
and state government resources to help
communities organize health care
networks to maximize their resources
in delivering health care.

For more details about the workshop
or rural health care networks, call the
Bureau’s Office of Rural Health Policy
at (304) 558-1327.

Two West Virginia
hospitals lead the
way in new program

Broaddus Hospital in Philippi and
Webster County Memorial Hospital in
Webster Springs have recently been
designated the state’s first and second
Rural Primary Care Hospitals, or
RPCH’s (rhymes with peach) and only
the second and third such facilities in
the nation.

The designations come as part of
the Essential Access Community
Hospital/Rural Primary Care Hospital
(EACH/RPCH) Program, designed to
improve the health care services of
rural communities by maximizing
available resources and reducing
duplicate services. Small, rural acute
care hospitals, such as Broaddus and
Webster, are converted to RPCHs and
linked with larger acute care hospitals
known as EACHs. Broaddus Hospital
will join forces with Davis Memorial
Hospital in Elkins, while Webster
Memorial will become a partner with
United Hospital Center in Clarksburg.

The process calls for the smaller
hospitals to change the way they
provide health care services, by
reducing their acute-care bed capacity
to no more than 12 beds. These

facilities also eliminate inpatient
surgical services and keep patients no
longer than 72 hours. Patients who
need acute care services are referred
to the EACHs. RPCHs maintain
emergency medical services and other
outpatient services that compliment
those already in the community. By
reducing competitive and costly acute
care services, smaller hospitals can
concentrate on enhancing primary
care and emergency services to better
meet the immediate needs of their
communities.

For more details concerning the
EACH/RPCH Program, contact the
Bureau’s Office of Rural Health Policy
at (304) 558-1327.

Immunization data
system planned

The Bureau of Public Health’s
Immunization Program is conducting
a needs analysis that will help in the
planning of a Statewide Immunization
Information System (SIIS).

As part of the needs analysis
process, a survey of health care
providers was conducted in Decem-
ber to measure their current computer
capacity. The positive response of the
medical community to this survey was
critical in generating an accurate
picture of the private sector.

When the SIIS is established, it will
serve as a depository of immunization
information for children born in West
Virginia. The concept behind the SIIS
will enable health care providers to
have immediate access to children’s
immunization histories at the time of
their visit for health care services.

This ensures that all providers have
accurate and current immunization
information which will save staff both
time and resources.

The support of the medical
community in the implementation of
the SIIS will be greatly appreciated.

All health care providers will reap
immediate and future benefits from
the project.

If you have any questions about
the planning for the SIIS, contact the
Bureau’s Immunization Program at
(304) 558-2188 or (800)-642-3634.

30 THE WEST VIRGINIA MEDICAL JOURNAL

Daniel Vannoy, JD, announces the opening of Vannoy Law Offices. His legal
practice focuses on business, civil, employment, health care and other areas of the law.

Formerly, Mr. Vannoy served as Associate General Counsel for the Health Sciences Center for
WVU, including the School of Medicine. Daniel has enjoyed providing legal advice, counsel
and representation to physicians at WVU.

Daniel Vannoy invites physicians and other health care practitioners throughout West Virginia
to contact Vannoy Law Offices for quality legal services. Mr. Vannoy encourages physicians
with business, hospital affairs, legal and/or regulatory concerns to retain legal counsel early
before those concerns develop into crisis.

Vannoy Law Offices

Daniel W. Vannoy

Attorney and Counselor-at-Law

Morgantown

81 3 Cottonwood Street
Morgantown, WV 26505
(304) 599-0535

Charleston

P.O. Box 408

Charleston, WV 25322-0408
(304) 345-0393

Mission: To provide quality consulting and legal-related services to businesses, governments

and individuals at competitive rates.

Our Name Says It Ai

i...

/^turn-key adj (1927]

: built, supplied,

or installed complete and ready to operate j

Webster's Ninth New Collegiate Dictionary j

Fast, efficient, effective, complete.

That’s Turnkey Business Systems,
an award-winning Medical Manager
dealer.

We specialize in the medical market,
tailoring practice management
systems to meet your special needs.

^Turnkey

Business Systems. Inc. •/

Lee Bldg. Suite 102 *30 W. Sixth Ave.
Huntington, WV 25701

(800) 242-5901 / (304) 522-4361

Robert C. Byrd

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
Uniiiersity, Communications Office, Morgantown.

Randolph County boy
gets heart checked via
MDTV from Congress

On November 5,
Dr. William Neal, a
children’s heart
specialist who
chairs the

Department of

- ■ j

Pediatrics, checked

% ■

in on one of his

■

rural patients via

Neal

MDTV from a

Senate office

building in Washington, D.C.

The exam was part of a
telemedicine demonstration organized
by Senator Jay Rockefeller to show
the applications of technology in
improving health care around the
world. The patient, 15-month-old
Jeremy Liggett of Mill Creek in
Randolph County, shared the spotlight
with a three-year-old in Moscow who
has a tumor. The Russian child was
examined over a satellite link
provided by NASA. The entire event
was telecast worldwide via satellite.

D’Alessandri receives
ACMGA award, named
to lead reform project

Dr. Robert
D’Alessandri, vice
president for health
sciences and dean
of the School of
Medicine, was
recently presented
with the 1993
Medical Executive
Award of the
American College of
Medical Group Administrators. The
annual award is given to one
physician in the United States who
exemplifies leadership in the field of
medical group practice.

D’Alessandri

Dr. D'Alessandri also has been
named chair of the West Virginia
Health Care Reform Project
(WVHCRP). Dr. Robert Walker,
professor and chair of family and
community health at Marshall
University, will be vice-chair. The
appointments were announced by
Senator Jay Rockefeller, who created
the WVHCRP to involve a wide
spectrum of West Virginians in the
creation of state and national
comprehensive health care reform.

WVU cardiologists
perform first stent
device procedure

Maxwell Jain

A man with a long history of heart
disease underwent the first coronary
procedure using a stent device at
WVU Hospitals on November 15. The
procedure was performed by Dr.
Abnash C. Jain, professor of cardiology,
and Dr. Leeman P. Maxwell, associate
professor of cardiology.

“This man was over 60 years old
and had bypass surgery in the past, as
well as two balloon angioplasties,” Dr.
Jain said. “The new procedure was
used to keep the artery open. The
stent device, which is a stainless steel
coil, was placed in the lining of the
artery to keep the walls from collapsing.”
“The balloon inflates and the coil is
pressed outward into the artery,” Dr.
Maxwell further explained. “It’s
designed so that, once it’s expanded,
radial force is exerted allowing the
blood to flow. This decreases the risk
of a heart attack or the need for
emergency bypass surgery7.”

The stent becomes a permanent
part of the artery, and because it is
stainless steel, the stent is not rejected
by the body.

Cancer Center using
new drug for patients

Metastron, a drug
approved in June
by the F.D.A. is
being used to treat
patients with
painful cancer
metastases of the
bones at the Mary
Babb Randolph
Cancer Center.
“Metastron, a
radioactive form of Strontium-89, is a
compound similar to calcium,” says
Dr. Leroy Korb, associate professor
and section chief of radiation
oncology. “It’s uptaken by bone in the
body, where it delivers a very precise
dose of intense radiation to the sites
of cancer metastases. The best
responses are in people who have
metastases from either breast or
prostate cancer.”

Metastron is so specific “its uptake
is either in the bone or it’s excreted
by the body," Dr. Korb explained.
“Therefore, the other organ systems of
the body — such as the bone marrow,
the liver and the heart — all receive
very low doses of radiation. “It has
very low toxicity. Side effects are
almost nil, and there are very few
contraindications to its use.”

Cancer program
granted ASC approval

The American College of Surgeons
has granted a three-year approval to
the cancer program at WVU Hospitals.

In his letter announcing the
committee’s approval, David P.
Winchester, M.D., F.A.C.S., medical
director of the Cancer Department,
wrote that “all elements appear to be
in place and functioning to provide
educational, multidisciplinary
exchange on cancer patient
management, to encourage quality
control and audits, and to monitor the
success of primary and secondary
treatment through long-term follow-
up.”

Dr. Mark Wax is chair of the WVUH
cancer committee.

32 THE WEST VIRGINIA MEDICAL JOURNAL

a West Virginia University school of Medicine

Office of Continuing Medical Education

Primary Care Perspectives on Women’s Health

February 18-20, 1994

Snowshoe Resort
Snowshoe, WV

Registration Form

Registration is recommended by February 4, 1994.

Name Degree

(MD, PhD, etc.)

Home Address

Work Address

City State Zip County

Day-time Telephone ( ) Home Telephone ( )

Social Security Number - - Affiliation

Specialty Subspecialty

Please specify the exact name to be printed on your certificate. Print or type name.

Course Fees*

Full conference

Friday conference
Saturday conference
Sunday conference

Price

$150.00

$40.00

$85.00

$60.00

*Course fees include conference materials, reception, Total

continental breakfast, and breaks.

Total

Credit Card payment: Please charge my dVisa DMasterCard Card number

Expiration date Authorization signature

Fax registration and credit card payment to (304) 293-4891 or mail form with payment to:

WVU Foundation

c/o Office of Continuing Medical Education
1250 Health Sciences South
PO Box 9080

Morgantown, WV 26506-9080

Special Requirements

If you require access and parking for the handicapped, please so indicate:

The West Virginia University School of Medicine is entitled by the Accreditation Council for Continuing Medical Education
(ACCME) to award credits in continuing medical education for physicians. The Office of CME certifies that this continuing medical
education activity meets criteria for 1 1.5 credit hours in Category 1 of the Physicians Recognition Award of the American Medical
Association.

For more information, please contact the WVU School of Medicine Office of CME at 1 -800-WVA-MARS or (304) 293-3937.

Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington.

Plans underway for
Center for Applied
Biotechnology

The Marshall University Foundation
has acquired the former Butler
Furniture Co. building at 434 20th St. to
house a proposed Marshall University
Center for Applied Biotechnology.

MU President J. Wade Gilley said the
university is retaining an architectural/
engineering firm to perform
programming studies and provide
renovation cost estimates. The
university is also seeking grants
through the National Institutes of
Health and the National Science
Foundation to cover renovation costs
for the building, which contains 18,900
square feet.

The Center for Applied Biotechnology
is being developed in three phases by
the School of Medicine under the
direction of Dr. L. Howard Aulick,
assistant dean for research
development. Phase 1 will be the
forensic science division, featuring a
state-of-the-art DNA typing facility.

This will consist of a cell molecular
biology laboratory designed to support
the accelerating demands for identity
testing by law enforcement agencies
and the courts. It also will serve as a
training center for a molecular-based
master’s degree in forensic science.

Phase 2, the medical sciences
division, will be developed through
creation of an advanced medical
diagnostics laboratory as an extension
of the DNA typing facility. It will
provide both DNA-based and non-
DNA-based clinical diagnostics,
emphasizing assays for cancer,
infectious diseases and genetic
diseases. Under the proposal, it will
feature only those educational,
research and clinical services not
available at existing local medical
facilities.

Phase 3, the environmental science
division, will focus on the research of

investigators in the College of Science
and the School of Medicine concerning
environmental effects with the long-
term goals of environmental
reclamation and restoration of health.

Dr. Terry W. Fenger, acting
chairman of Marshall’s Department of
Microbiology, Immunology and
Molecular Genetics, told Marshall’s
Faculty Senate he hopes to have the
forensic science division, including the
master’s degree program, initiated by
fall 1995. The Phase 1 proposal has
been approved by the Faculty Senate
and by Gilley. It will be submitted to
the University of West Virginia Board
of Trustees for final approval.

“These are the types of programs
that will put Marshall in the forefront
of scientific research, education and
application in the years ahead,” Gilley
said. “Even more importantly, they will
prepare students for the kinds of jobs
our region will need to prosper in the
future.”

Cabell Huntington
proceeds with plans
for outpatient center

Cabell Huntington Hospital in late
December took the next step toward a
new outpatient center for the Marshall
University School of Medicine by
submitting a letter of intent to the West
Virginia Health Care Cost Review
Authority (HCCRA).

The hospital’s Certificate of Need
application was expected to be filed in
time for the upcoming HCCRA review
cycle. HCCRA ruled last month that the
original letter of intent, submitted early
in the planning process, needed to be
updated. The new letter describes
associated projects, such as Marshall’s
federally- funded Center for Rural
Health, that were not known when the
original letter was filed.

The new letter also includes, at
HCCRA’s request, information on
future projects that could or would
result from developing the complex.
The document proposes construction
of a complex that includes the
outpatient care center, Marshall’s
Center for Rural Health, and academic
and administrative space.

MARSHAlIMJNIVERSITY

The four-story outpatient center will
provide patient care areas and faculty
offices for the school’s departments of
Family and Community Health,

Medicine, Obstetrics/Gynecology,
Pediatrics and Surgery. The Center for
Rural Health, located next to the
outpatient center, will serve as the hub
of the school’s rural medicine activities.
The academic health space, which will
be added if private fund-raising is
successful, will provide support space
for the Department of Psychiatry and
administrative offices for the School of
Medicine.

In addition to the medical center
complex, the project plan includes a
connector to link it to the hospital.

The connector would tie in with a new 1
main entrance and lobby for the
hospital, as well as with a
reconfiguration of the patient
registration area. Cabell Huntington
Hospital will pay the estimated $3-9
million to make these changes.

Nurse practitioner
program granted
initial accreditation

The master of science in nursing —
family nurse practitioner program has
received initial accreditation from the
National League for Nursing, School of
Nursing Dean Lynne B. Welch has
announced.

The accreditation is retroactive to
1992. The league scheduled a site visit
for reaccreditation in spring 1998.

The Marshall program, developed in
response to West Virginia’s need for
qualified mid-level health professionals,
graduated its first class in 1992. West
Virginia students in the program have
come from Raleigh, Logan, Wayne,
Kanawha, Cabell, Lincoln, Putnam and
Wood counties. Participants have
done most of their clinics in
underserved areas of Boone, Jackson,
Wayne, Cabell, Kanawha, Putnam and
Lincoln counties.

34 THE WEST VIRGINIA MEDICAL JOURNAL

West Virginia Medical

OURNAL

West Virginia State Medical Association Volume 90 No. 2

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

STACKS

MAR 4 1334

RECEL NQI G1RG»

UNIVERSITY OF MARYLAND
MLTH. SCIENCES LIB. -ACQ. DEPT
111 SOUTH GREENE STREET
BALTIMORE MD 21201

Sometimes Being Sure Of
Yourself Just Isn't Enough.

Investing Our People
In Your Future.

You know you are a
good doctor, you've
worked hard to get
where you are but
sometimes being sure
of yourself just isn't
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McDonough Caperton
professionals are
dedicated to our clients
and their future. It's an
investment on both our
parts and a trust we
cherish. McDonough
Caperton, insurance
advisor to the West
Virginia State Medical
Association —
committed to people.
Dedicated
to excellence.

McDonough

Caperton

Insurance

Group

Corporate Headquarters One Hillcrest Drive, P.O. Box 1551, Charleston, WV 25326-1551, Telephone: (304) 346-0611 Fax: (304) 347-0697
With Offices Located in: Florida, Georgia, Kentucky, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Bermuda

EDITOR

Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Published monthly by the West Virginia
State Medical Association under the direction
of the Publication Committee. Original
articles are accepted on the condition that
they are contributed solely to the West
Virginia Medical Journal.

Postmaster send form 3579 to the West
Virginia Medical Journal. 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston. West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL JOURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $36 a year in the U.S.;
$60 in foreign countries; S3 per single copy.
Address communications to the West
Virginia Medical Journal. P. O. Box 4106,
Charleston, WV 25364.

Due to increasing publication and mailing
costs, the West Virginia Medical Journal will
not honor claims for back issues for any
reason, unless these claims are received
within a 6-month period after issue of the
_ publication requested.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Road,
Ann Arbor, MI 48106.

USPS 676 740
ISSN 0043 - 3284

West Virginia Medical

OURNAL

Contents

Feature Articles

Employment, race and poverty in West Virginia:

Implications for practicing physicians 46

Increasing screenings for breast and cervical cancer

in West Virginia 50

Special Reports

An overview of the AMA Interim Meeting 52

An overview of the HMSS Assembly Meeting 53

Scientific Newsfront

Stabilization of hand phalangeal fractures by external fixator 54

Rational treatment for dyslipidemias 58

Contact Nd: YAG laser excision of rhinophyma 62

President’s Page

Tinkering with the equation for access 64

Editorials

The Pitchmen 65

Non-game wildlife programs 65

Special Correspondence 66

Special Departments

General News 68

Continuing Medical Education 70

Medical Meetings/Poetry Corner 71

Bureau of Public Health News 72

Robert C. Byrd Health Sciences Center News 74

Marshall University School of Medicine News 76

WESPAC Members 78, 79

New Members/Society News 79

Obituaries 80

Classified 81

February Advertisers 82

lOURNAL _

Front Cover

A hiker views a wintry scene on Lindy Run Overlook at
Blackwater Canyon in Tucker County. Photo courtesy of
Stephen J. Shaluta Jr., West Virginia Division of Tourism
and Parks.

FEBRUARY 1994, VOL. 90 45

Feature Article

Employment, race and poverty in West Virginia:
Implications for practicing physicians

ROBERT M. FRUMKIN, Ph.D., F.A.A.A.S.
Associate Professor, Humanities and Social
Sciences Department, Salem-Teikyo University,
Salem, W. Va

Abstract

Since West Virginia became a state
in 1863 and slavery was abolished,
poverty has been a persistent
problem for black Americans.
Although blacks have become
increasingly a part of the total
workforce, moving from the lowest
level, lowest paid jobs to higher
level, better paying ones,
unemployment, poverty, and their
common sequelae still persist and
significantly differentiate black
from white Americans. While racial
discrimination has been a factor in
black poverty for many decades,
another critical factor responsible
for black poverty today and in the
past, is something which both blacks
and physicians can help to change -
unplanned parenthood.

Introduction

Since World War II, physicians have
become increasingly aware of the fact
that race is a critical factor in the
health of the communities and the
patients which they are called upon to
serve (1). To be black in America
means, in health and social terms, to
be subject to significant differential
categoric risks for unemployment,
mental disorders, various medical
disorders (other than mental), drug
abuse, crime, poverty, and a host of
other unfavorable conditions (2).

While living conditions for blacks
nationally have been relatively poorer
than for whites, it is known that
individual states vary much in terms of
the actual conditions and problems
experienced by blacks. For example,
Ohio, as compared to New York, has
had significantly more black
unemployment with all its dire
consequences (2). This article is

designed to evaluate the living
conditions of blacks in West Virginia
and examine the implications for
practicing physicians.

Historical background

During the great Civil War, the
western countries of Virginia, which
favored the abolition of slavery, broke
away from the rest of the state and
formed the new state of West Virginia
(June 20, 1863). The new state formed
its own government and was loyal to
the Union forces. Even though West
Virginia was loyal to the Union, that
did not mean that there did not exist
bigotry towards blacks. But, West
Virginia, on the whole, seemed to be
relatively free of the virulent kind of
racism rampant in other parts of the
United States.

The desire of the western counties
of Virginia to form an independent
government was not new in 1863- As
early as 1776, these citizens petitioned
for their own government. Whereas,
the eastern counties of Virginia had an
aristocratic lifestyle, based mostly on
wealthy tobacco plantations, the
western counties had a hardworking,
frontier lifestyle which consisted
mainly of farming and raising livestock.

One big disagreement between the
western and eastern sections
concerned the tax break easterners
received for owning slaves. First,
black slaves under 12 years of age
were exempt from taxation and the
slaves that were older could not be
assessed in excess of $300. The
easterners got the best transportation
breaks, such as an adequate system of
railroads, while the western counties
always seemed to get second-class
state allocations because the
aristocratic eastern counties controlled
the state. Thus, contrary to popular
current opinion, the matter of slavery
was not, per se, the central issue
between the eastern and western
counties. It was rather the differential
control of power and all its many
practical consequences (3).

To understand the status of blacks

in America society today, it is
imperative to examine the history of
blacks in the American slave economy
and their experiences following the
Civil War and the Emancipation
Proclamation. At the time of slavery,
except for free blacks, all blacks were
part of southern agriculture or were
household servants. As late as 1900,
this was a fact for 87 percent and even
in 1910, it was 80 percent. However,
by I960 less than 10 percent of blacks
were employed in agriculture and 15
percent in domestic service positions.
In fact, by I960, about 10 percent
were employed in professional and
semi-professional occupations.

The movement for blacks, from
agricultural to non-agricultural work,
seems to have been influenced by
these five factors:

1. Job competition between blacks
and whites, especially southern
whites and European immigrants.

2. Handicaps blacks have had
because of their slave origins, i.e.
undeveloped skills, poor
education, etc.

3. Black progress in jobs has been
related to periods of great labor
demand and low rates of
unemployment. Most jobs for
blacks were low-paying ones
which whites did not want.

4. The greatest opportunities have
been in expanding industries
during rapid growth, but not in
stable or declining industries.

5. Most progress made by blacks has
been made in areas such as
education and public health where
government was heavily involved.
Military service has also been very
popular, and black employment in
government agencies has been
substantial.

The changing nature of black
employment in the United States since
the Civil War is a fascinating topic
much too complex to deal with in this
short paper (4). In spite of everything,
blacks have managed to expand their
job alternatives, but, in our depressed
economy, the maintenance of job

. ■ T A;:;;!; t

46 THE WEST VIRGINIA MEDICAL JOURNAL

TABLE 1 Poverty Status of West Virginia Families by Race in 1969, 1979 and 1989
(Percent Income Less Than Poverty Line)

Year

White

Black

Ratio

1989

19.1%

36.0%

1.9%

1979

11.4%

21.4%

1.9%

1969

17.5%

31.9%

1.8%

TABLE 2. Occupations of Blacks in I960 and 1980 in West Virginia

Occupation

I960

1980

Percent Change

Professional, Technical

7.3%

10.5%

+3.2%

Managerial

1.6%

5.5%

+3.9%

Clerical, Sales

4.6%

25.7%

+21.1%

Service

42.0%

26.3%

-15.7%

Skilled

4.9%

11.2%

+6.3%

Semi-skilled & Unskilled

38.0%

19.3%

-18.7%

Farming

1.6%

1.5%

-0.1%

100.0%

TABLE 3- Unemployment for Blacks and Whites in the U.S. in 1970, 1980 and 1990

1970

1980

1220

Total

4.9%

7.1%

5.5%

Male

4.4%

6.9%

5.6%

Female

5.9%

7.4%

5.4%

Race

Whites

6.3%

4.7%

Blacks

14.3%

11.3%

White) Black Ratio

2.3%

2.4%

*No white) black data for the 1970 census.

TABLE 4. Unemployment for Blacks and Whites in West Virginia in 1970, 1980 and 1990

1970

1980

1990

Whites

Total

5.1%

8.3%

9.4%

Male

4.9%

9.1%

10.1%

Female

5.4%

7.1%

8.4%

Blacks

Total

7.0%

12.3%

17.3%

Male

6.6%

14.3%

18.4%

Female

7.6%

10.1%

16.2%

White) Black Ratios

Total

1.4%

1.5%

1.8%

Male

1.3%

1.6%

1.8%

Female

1.4%

1.9%

i stability has been a persistent
problem.

Race and poverty in West Virginia

Prior to the 1970 U.S. Census,
poverty statistics were not published.
What we do have for previous years is
a reasonable substitute for such
statistics when we examine family
income. For example, in 1959 in West
Virginia, the median income for all
families was $4,572. For non-white
families (virtually all black) it was
$2,874. Non-white family income was
63 percent of white family income. At
that time, with no poverty status
guides firmly set, it was felt that an
annual income between $2,000 and
$4,000 meant that such families were
growing up “under adverse economic
circumstances” (5).

The 1970, 1980 and 1990 U.S.
Censuses have provided definitive
data as shown in Table 1. For West
Virginia, we may now compare white
and black poverty levels for those
periods. Table 1 shows that if we
define poor as being a member of a
family whose income is less than the
poverty level established by the U.S.
Census, then, for the past two
decades, blacks in West Virginia have
been almost twice as poor as whites.

Employment and unemployment

There are two aspects important to
the issue of employment. First, there
is the matter of being employed or
not being employed. Having a job,
not being unemployed is critical.
Second, there is the question of the
type of employment, that is, is it a
position requiring just a few skills
which is long on hours and short on
wages, or is it a skilled job which
pays a wage which can help sustain a
decent standard of living?

When blacks left farming and
domestic service jobs to seek a better
way of life, most obtained mainly
low-paying jobs requiring minimal
skills because they were so poorly
educated. As the levels of education
of blacks have increased and higher
level, higher-paying jobs have become
available, the picture of the
employment demographics for blacks
has changed significantly. Table 2
shows how dramatically the
occupations of blacks in West Virginia
changed from I960 as compared to
1980.

But how do blacks compare with
whites in West Virginia with respect to
unemployment? During the war on
poverty and the Vietnam War,
unemployment rates for whites and

blacks were relatively low. However,
in 1980 and 1990, unemployment was
significantly higher for blacks
compared to whites.

Table 3 presents us with the national
unemployment picture and Table 4
provides details on unemployment in
West Virginia. Examination of these
two tables show us that nationally,
unemployment for blacks is more
than twice that of whites. However, in
West Virginia, the unemployment
rates have been better than the

national picture, yet, by 1990, were
still approaching a rate twice as great
as the unemployment rates for whites.
Numerous studies of unemployment
provide us with evidence that serious
health and social problems are
associated with high rates of
unemployment (6,7).

In West Virginia in 1989, the mean
household income for white families
was $27,226, but $18,904 for black
families. For 1989, a family of four
persons with an annual income of

FEBRUARY 1994, VOL. 90 47

TABLE 5. Size and Race of Families in the U.S. Below Poverty Level in 1989

Percent Below Poverty Level

All Races

White

Black

Total

10.3%

7.8%

27.8%

Size of Family

Two Persons

8.2%

6.6%

22.7%

Three Persons

9.8%

7.1%

27.3%

Four Persons

10.1%

8.0%

25.8%

Five Persons

13.5%

10.3%

33.2%

Six Persons

21.1%

15.6%

44.3%

Seven Persons

32.3%

25.5%

51.2%

Source: U.S. Bureau of the Census, Current Population Reports, Series P-60, No. 168, 1991.

$12,674 or less was considered as
living below the poverty level. Using
that definition, 19.1 percent of whites
and 36.0 percent of blacks in West
Virginia lived in poor families. Thus,
the ratio of black families in poverty
as compared to whites was
approximately double.

Implications for practicing
physicians

Although blacks in West Virginia
have shown significant gains in
moving from less skilled jobs to
higher level occupations (Table 2), the
ratio of black to white families living
in poverty is approximately double
(Table 1 ). Nationally, blacks have
experienced more than two times the
unemployment rates for whites (Table
3).

While unemployment rates for
blacks in West Virginia has been
significantly less than the national
rate, it is still almost twice that for
whites (Table 4). The question
remains as to why, with the increase
of blacks in higher level occupations,
is there still so much poverty among
blacks as compared to whites?

When Dr. Jocelyn Elders recently
became the U.S. Surgeon General, in
her acceptance speech, she hinted as
to how any family can reduce their
risk for poverty and the ill health
which often becomes its partner. She

simply said that planned parenthood
must be central to any national health
plan because unplanned families are a
major source of poverty and ill health.
While we have, as yet, no state figures
on the relationship of poverty to
family size, it has been shown
nationally that there is almost a
geometric increase in poverty with the
increase in family size and that among
blacks, as compared to whites, large,
presumably unplanned families are
factors in this relationship (Table 5).
This philosophy is also described by
sociologist Dr. Clifford Kirkpatrick in
his book “The Family,” when he states
“The economic implications of
differential fertility have the utmost
significance. A group which because
of race cannot control job supply may
thrive or suffer, depending on fertility”
(8).

If West Virginia and the United
States is to have a successful national
health plan, then physicians must
become advocates for planned
parenthood in both their practice of
medicine and as responsible public
citizens. When anti-abortionists are
critical of physicians supporting
planned parenthood, physicians must
respond to such challenges by
pointing out that they are not so
much pro-abortion as much as they
are against unplanned pregnancies
which often lead to multiple health
and social problems. They must

48 THE WEST VIRGINIA MEDICAL JOURNAL

emphasize, as Dr. Elders has, that
abortions are generally necessary only
when people have irresponsible sex
relations, when they permit
unplanned pregnancies to take place.

A successful national health plan is
inconceivable without planned
parenthood. The poverty of blacks as
compared to whites, nationally and in
West Virginia, is related in a
significant degree to unplanned
parenthood and its many correlates.
Examination of Table 5 shows the
national picture in a dramatic way and
I feel every practicing physician has a
vital role in the success of any
national health plan and the West
Virginia health plan.

Acknowledgments

The author thanks Stephanie Pratt
and Alex Lubman of the Office of
Health Services Research, Department
of Community Medicine, West Virginia
University, Morgantown, for their help
in providing much of the statistical
data summarized in tables and
discussed in this paper. He also wants
to thank Dr. Phyllis Freedman,
director of the Library at Salem-Teikyo
University in Salem, for providing
important governmental and historical
materials needed to complete this
paper.

References

1. Frumkin RM. The patient as a human being.
In: The race of patients. Buffalo: University
of Buffalo, 1956.

2. Frumkin RM. Race, occupation, and social
class in Ohio. J Negro Educ 1954; 23:492-5.

3. Ambler CH, Summers FP. West Virginia. New
York: Norton, 1976.

4. Ross AM. The negro in the American
economy. In: Ross AM, Hill H, editors.
Employment, race and poverty. New York:
Harcourt, Brace and World, 1967:3-48.

5. Ginzburg E, Hiestand DL. The guidance of
Negro youth. In: Ross AM, Hill H, editors.
Employment, race, and poverty. New York:
Harcourt, Brace and World, 1967:435-59.

6. Frumkin RM Race, occupation, and social
class in New York. J Negro Educ 1958; 27:
62-5.

7. Frumkin RM. Race of men serving life
sentences in the Ohio penitentiary. I Negro
Educ 1955:24:506-8.

8. Kirkpatrick C. The family. New York: Ronald
Press, 1955:472.

A THOUGHT FOR
EVERYONE WHO RESENTS
SITTING AT A DESK
EIGHT HOURS A DAY.

Neuromuscular disease.

It's a large group of disorders that weaken muscles and
nerves — devastating thousands of Americans each year.

When neuromuscular disease strikes, many muscle functions
are lost. So writers can't write. Musicians can't play. Teenagers can't
dance. Babies can't cry. Many patients lose the ability to walk.

And once they're in wheelchairs, they'll never get out.

The Muscular Dystrophy Association is striving to cure
40 neuromuscular disorders, including ALS ("Lou Gehrig's
disease") and myasthenia gravis. MDA maintains some 230 clinics
around the country to help people with muscle diseases. And MDA
provides orthopedic equipment and other aids for daily living,
all free of charge to patients and their families.

You can help MDA fight neuromuscular disease by sending
a tax-deductible contribution today. The Association receives no
government grants or patient fees, so its work is funded entirely by
private donations.

Next time you think you've been sitting too long, sit one more
minute and write a check. You'll be helping thousands of patients
stand up to their disease.

Muscular Dystrophy Association, Jerry Lewis, National Chairman

To make a donation or bequest to MDA, or for more information on MDA and ALS, write to:
Muscular Dystrophy Association, 810 Seventh Avenue, New York, NY 10019.

Or contact your local MDA office.

MDA ® is a registered service mark of Muscular Dystrophy Association. Inc.

PATIENTS

NORTHERN WEST VIRGINIA
PAIN MANAGEMENT CENTER
IS AVAILABLE TO HELP WITH
CHRONIC PAIN PATIENTS.

WE SPECIALIZE IN CANCER
PAIN, BACK PAIN, SYMPATHETIC
DYSTROPHIES, MYOFASCIAL
PAIN AND HEADACHES.

WITH TWO

CONVENIENT LOCATIONS:

99 J.D. ANDERSON DR.
MORGANTOWN, WV

DOCTORS OFFICE BLDG.
SUITE 205
CLARKSBURG, WV

Richard M. Vaglienti, MD, F.A.C.P.M.
Matthew E. Midcap, MD, F.A.C.P.M.
Stanford J. Huber, MD

For More Information
or Patient Referrals

;;

Increasing screenings for breast and cervical
cancer in West Virginia

R. JOHN C. PEARSON, M.B., M.P.H.

Professor and Chairman, Department of
Community Medicine, West Virginia
University School of Medicine

KEN SIMON, Ed.D.

Mary Babb Randolph Cancer Center
CECIL POLLARD, M.A.

Office of Health Services Research

VALERIE FREY-McCLUNG, M.A.

Office of Health Services Research

Robert C Byrd Health Sciences Center of West

Virginia University, Morgantown, W. Va.

Introduction

There is, by now, no doubl that Pap
smears have been effective in
reducing the frequency of invasive
cancer of the cervix and the number
of deaths that result from this
condition. The challenge continues
though for physicians to encourage all
of their female patients to have Pap
smears, especially women who are at
higher risk of developing cervical
cancer. Of the 40 to 50 West Virginia
women who die of cervical cancer
each year, almost all of them have not
have a Pap smear for at least three
years.

There is also the expectation that
the use of mammography will, in due
course, reduce mortality from breast
cancer. Certainly, the tumors can be
found at an earlier stage and less
mutilating operations are possible, but
again, the challenge is to get women
to receive the test.

The most convenient and cost-
effective way that women can obtain
both a Pap smear as well as have a
mammogram performed, is for both of
these tests to be offered to them when
they visit their primary care physician.
To study the procedures of primary
care physicians in West Virginia in
regards to Pap smears and mammograms,
a questionnaire was mailed randomly
in late spring of 1992 to 440 family or
general practitioners, general internists
and ob/gyns.

Methods

A total of 440 West Virginia family
or general practitioners, general
internists, and ob/gyns were randomly
selected from the M.D. licensure rolls
and mailed a questionnaire in late
spring 1992. This represented about
one fourth of the entire licensure list
in these categories. The questionnaire
asked about office practice procedures
and characteristics, referral patterns,
and continuing medical education
topic choices.

One week after the questionnaire
had been mailed, a postcard was sent
to these same physicians to thank
those that had responded and
encourage those that had not
answered the questionnaire to still
respond. In addition, a second copy
of the questionnaire was mailed to
those who did not respond three
weeks after the initial mailing, and
another follow-up reminder was
conducted by phone three weeks
later.

Out of the original sample of 440
physicians, it was discovered that 16
had retired, 22 were practicing
specialties not related to the
questionnaire, 11 had relocated, and
two had died. This now brought the

total number of physicians in the
sample to 389, and of this number,

178 completed the questionnaire for a
total response rate of 46%.

Findings

The questionnaire revealed that
most physicians do screen in their
office practices for both Pap smears
(92%) and clinical breast examinations
(97%). In addition, 23% perform
colposcopies, 22% cauterize cervixes,
15% perform conizations, and 10%
perform needle biopsies of the breast.

In terms of seeing whether
individual patients making an office
visit are up-to-date with their
screening, 28% have their office staff
flag the chart, 8% have a computer
printout, and 10% do not have a
particular method. Most (85%) rely
upon their own review of the chart to
see whether screening is indicated.

The study discovered that 74% of
these physicians responding had no
procedure for contacting female
patients at home to remind them to
have Pap smears and mammograms,
that one in five (19%) rely on manual
chart reviews to find the women who
need screenings, and that only 6%
have help from a computer.

FIGURE 1

WHAT CME THE PHYSICIANS SURVEYED WANT FOR THEMSELVES AND THEIR STAFFS

Percent 0

Current perspective on breast and
cervical cancer prevention,
screening, diagnosis, treatment

Update on clinical
breast/Pap techniques

Office management techniques re:
screening and reminder systems

Update on mammography techniques
and interpretation of results

Using computers in
office practice

Teaching your patients to do
breast sell-examination

100

office staff

50 THE WEST VIRGINIA MEDICAL JOURNAL

When an abnormal finding is
reported on the smear or
- mammogram, 87% of the physicians
questioned contact these patients by
mail or phone. However, the
remaining 13% said they waited for
| the women to take the initiative.

The questionnaire also provided
valuable insights into what types of
continuing education could benefit
these physicians and their staffs
(Figure 1). The physicians expressed
at least a 40% interest in programs
relating to office management skills,
use of computers in clinical practice,
and teaching patients breast self-
examination for both themselves and
their staff. In addition, at least 50% of
the physicians wanted CME on current
perspectives on screening, techniques
of screening, and mammography
interpretation.

Discussion

Pap smears and mammograms are
' two screening activities which are
slowly being included in the regular
office practice of medicine. It is
obvious, though, that there is a lack of
office procedures that make the need

for screening automatically detected
without too much effort on the part of
physicians and their staffs.

Fewer than half of the primary care
physicians questioned utilized a
computer, “tickler file,” or colorcoding
of patient record folders to alert
themselves to the fact that it was time
for one or both of these screenings for
their patients. In addition, the study
revealed that a small portion of
physicians do not even notify patients
of an abnormal finding on Pap smears
or mammograms. This is a critical
situation that needs attention.

The challenge now is to develop
materials that will facilitate the
incorporation of these screening
procedures into regular office
practice. Simple reminder systems,
both manual and computerized, that
can trigger letters to patients
reminding them that they are due for
exams need to be made available to
practices that would like to use them.
CME programs can include these
systems to maximize dissemination
and give instructions on their use.

One important way that brochures
and CME programs regarding breast

and cervical cancer screenings is
being distributed is through the Breast
and Cervical Screening Program, a
CDC-funded program of the West
Virginia State Bureau of Public Health,
provided by the Mary Babb Randolph
Cancer Center at the Robert C. Byrd
Health Sciences Center of West
Virginia University. Sample materials
and information can be obtained by
calling the Cancer Information Service
at 1 -800-4-CANCER.

A computerized screening and
tracking tool that will work effectively
on any PC compatible 286, 386 or 486
system, as well as generate letters, is
available free of charge from the
Office of Health Services Research,
Robert C. Byrd Health Sciences
Center of West Virginia University,
Morgantown, WV 26505-9350;

(304) 293-2370.

Acknowledgement

The authors wish to thank the West
Virginia Bureau of Public Health and
the Centers for Disease Control for
funding this study.

21st Annual Newborn Day

"Metabolic Disorders of the Newborn"

March 25, 1994

The 21st Annual Newborn Day features
lectures and discussions on a variety of
general obstetrical and neonatal issues. This
conference, approved for 5.2 hours CME,
covers a variety of topics including; the role
of genetics in prenatal diagnosis, clinical
management of metabolic disorders of the
newborn, the management of low
birthweight infants and the diagnosis and
treatment of infants with ambiguous
genitalia.

Charleston Faculty:

Stefan Maxwell, MD
Fereydoun Zangeneh, MD
Todd Wandstrat, Pharm D

Guest Facull

Paul Benke, MD, PhD
Professor of Clinical Genetics, Director
of Clinical Genetics, University of Miami
(Florida) School of Medicine

William Cleveland, MD
Professor of Pediatrics, Director of
Endocrinology University of Miami
(Florida) School of Medicine

Jose Perez-Rogriguez, MD
Pediatric Endocrinologist, Clinical
Assistant Professor for Department of
Pediatrics, University of Miami (Florida)
School of Medicine

Location:

Robert C. Byrd Health Sciences Center
of West Virginia University, Charleston
Division

For information, contact:

Charleston Area Medical Center,
Continuing Education and Conference
Services, 348-9581.

Charleston Area
Medical Center

FEBRUARY 1994, VOL. 90 51

An overview of the AMA Interim Meeting

Members of the WVSMA’s delegation at the AMA Interim Meeting included Dr. John Markey; WVSMA President-Elect
Dr. Dennis Burton; WVSMA Senior Councilor at Large Dr. Constantino Amores; WVSMA Council Chairman Dr.
Robert Pulliam; WVSMA Associate Executive Director Nancie Diwens; Dr. Stephen Thilen; Dr. David Avery; Dr.
Stephen Sebert; WVSMA Vice President Dr. James Helsley; and Dr. Robert Hess.

i *!

The 1993 Interim Meeting of the AMA House of
Delegates was held in New Orleans from December 5-8. A
total of 193 resolutions and 101 reports were debated and
discussed at length at this meeting, with the major issue
being the AMA’s stand on health system reform.

I served on Reference Committee D which was involved
with the issue of public health. To help the AMA
leadership address the issue of health care reform, the
House adopted these guidelines after hearing testimony
from numerous physicians:

1 . The AMA reaffirms its support for universal coverage
and access to health care services.

2. The AMA supports the right for an individual to select
his or her own health care plan.

3. The AMA recognizes an individual’s health insurance
as an alternative to employer-financed health care.

4. The AMA recognizes the needs of small businesses
and the self-employed.

5. The AMA endorses and promotes health care savings
accounts as an option to assure patients freedom of
choice.

6. The AMA voted not to limit itself to a mandated
employer health care benefit system under health
care system reform. This brought the most press of
any of the issues. It was not a retraction of prior
commitments to mandated employer health benefits,
but a request that other policies be offered. The
health care benefits were to either be purchased by
the vendors themselves, or by employers. Some

people took this view as a means of backing away
from the government’s proposal, but I believe in
reality it was a measure to allow other options in
health care reform to be presented.

7. The AMA agrees to continue to work diligently to
ensure any health reform that was passed encompass
and limit all federal, state, and local employees to the
same degree as the general population; in other
words to make them live under the same insurance
and rules that are proposed for everyone else.

The bottom line was that the House of Delegates voted
to only support health care system reforms that:

1) Included universal access;

2) Did not feature rationing of care;

3) Included reasonable basic benefits;

4) That were not biased towards managed care, and

5) Included a true fee-for-service option with balance
billing.

In addition, the members of the House of Delegates
stated that any health care reform plan must preserve a
high quality of patient care; provide meaningful antitrust
relief, including the ability of state and county associations
to form partnerships; provide true tort reform; provide
significant insurance market reforms, and to recognize
physicians' responsibility and authority in making
decisions regarding medical issues.

52 THE WEST VIRGINIA MEDICAL JOURNAL

A resolution was passed calling for continued AMA
opposition to the national health board that is currently
being proposed by the Clinton administration and
supporting the creation of a national health advisory body
that will form a private partnership to recommend health
policy. Another goal discussed by the House members was
to make sure that physicians were not excluded
inappropriately by different managed care organizations
by requiring managed care organizations and third-party
payors to disclose the criteria used to select and retain
physicians. Members also felt that physicians participating
in these plans must be able to treat and take care of
patients without the threat of punitive action.

Regarding professional liability reform, the AMA is again
pushing for a $250,000 ceiling on non-economic damages;
the collateral source rule and decreasing incremental or
sliding scale contingency fees; periodic payments for
future awards; and a limitation of the statute of limitations
to no more than six years after birth. House members
w^ere also asking for federal reform to require a certificate
of merit before filing a medical liability case; for statutory
criteria to outline expert witness qualifications; and for
demonstration projects to be set-up as alternate dispute
resolution mechanisms.

The House of Delegates passed resolutions asking for
regulations regarding firearm control. These included
mandatory destruction of any wreapons in buy-back
programs and supporting legislation to outlaw Black Talon
or similarly constructed bullets. This resolution also
reaffirmed a current AMA policy supporting waiting
periods and background checks for purchases of firearms.

The House members also adopted a very strong
resolution condemning the practice of providing economic

incentives to pharmacists in exchange for persuading
physicians to therapeutic interchange. They also reaffirmed
the AMA’s opposition to payment to physicians in
response for prescribing practices and stated that they
consider it inappropriate for payment of any economic
incentives for the purpose of influencing decisions.

In addition to this overall report on the meeting and
Reference Committee D on Public Health, the other
members of the WVSMA delegation also served on
committees, and they have prepared reports which are
available at the WVSMA office. These delegates and the
names of their committees are as follows:

Reference Committee on Amendments Dr. Comerci

to Constitution and Bylaws

Reference Committee A
(Medical Service)

Reference Committee B
(Legislation )

Reference Committee C
( Medical Education )

Reference Committee E
(Science and Technology)

Reference Committee F
(Board of Trustees)

Reference Committee G
( Medical Practice/Facilities )

Reference Committee H Dr. Pulliam

(Health Care Data Systems)

David W. Avery, M.D.
AMA Delegate

Dr. Thilen
Dr. Markey
Dr. Sebert
Dr. Helsley
Dr. Amores
Dr. Hess

An overview of the HMSS Assembly Meeting

The 22nd AMA-HMSS Assembly Meeting was conducted
December 2-6 in New Orleans with 412 credentialed
representatives in attendance.

The AMA-HMSS considered 43 resolutions and 30 HMSS
Governing Council reports. The Assembly action included:
24 resolutions adopted; five resolutions supported in lieu
of a resolution; seven resolutions referred to the
Governing Council, and seven resolutions not adopted. Of
the Governing Council reports, 23 reports wrere adopted,
six reports were filed, and one report was not adopted.

Ten of the resolutions were forwarded to the AMA
House of Delegates for consideration at the 1994 Interim
Meeting. In addition, the House considered four HMSS
resolutions which were transmitted from the 1993 Annual
Assembly Meeting.

The AMA House of Delegates adopted 1 1 of the HMSS
resolutions, referred two resolutions to the Board of
Trustees, and referred one resolution to the Board of
Trustees for decision.

A resolution recommending review and updating of
guidelines for medical staff bylaws was among the actions
taken by the AMA House of Delegates. In lieu of
Resolutions 107 and 148, the House of Delegates adopted
Substitute Resolution 107 which asked the following:

That the AMA reaffirm its Policy 165-960 (C) (1), in
opposition to a National Health Board of the sort
currently proposed by the Administration, and that
Policy 165.945(1) (D) be amended by insertion and
deletion to read as follows: “The AMA supports the

creation of a National Health Advisory Body or Task
Force that will form a public/private partnership
including the AMA to recommend health policy.”

In addition, the House of Delegates referred Resolution
822 to the Board of Trustees for report back to the House
of Delegates at the 1994 Annual Meeting. This resolution
called for the AMA to study the issue of physician
representation in organizations such as group practices,
independent practice associations, the physician
component of a physician-hospital organization, physician
networks, and other types of future arrangements that may
form. It also requested the AMA designate the AMA-HMSS as
the vehicle for providing representation to physicians
providing services in these entities.

Another important action of the members of the House
of Delegates was that they advised the AMA to oppose all
efforts to open the National Practitioner Data Bank to public
access. In addition, the members asked that the AMA
strongly oppose public access to medical malpractice
payment information in the National Practitioner Data
Bank, and that the AMA oppose the implementation by the
National Practitioner Data Bank of a self-query user fee.

Other topics of discussion at the meeting included
conflict of interest among all components of the health
care system and legislation to control handguns.

Norman W. Taylor, M.D.

Raleigh General Hospital Delegate to HMSS

Chairman, WVSMA-HMSS

FEBRUARY 1994, VOL. 90 53

Scientific Newsfroet I

—

Stabilization of hand phalangeal fractures by
external fixator

JULIO HOCHBERG, M.D., F.A.C.S.
MARCOS ARDENGHY, M.D.

Section of Plastic Surgery, West Virginia
University, Morgantown, W.Va.

Abstract

The method of external fixation of
phalangeal fractures provides a
solution for extensive hand injuries
where internal fixation may he
prohibited due to compromised skin
coverage or bone loss. Early
mobilization of adjacent joints is
possible with these devices and is
fundamental for the preservation of
hand function. This paper describes
the proper selection of cases and
the versatility of its application.
Representative clinical uses are
summarized.

Introduction

In hand injuries, the combination of
skeletal fractures and severe soft tissue
damage represents a difficult
management problem, especially in
comminuted phalangeal fractures with

bone loss. External fixation is a
modern method that provides stability
and good alignment of the fracture
(Figure 1) and permits early
mobilization of adjacent joints.

This article describes three cases in
which external fixation was used with
good results and outlines the indications
and technical details of these method.

Case reports

First case

A 15-year-old boy sustained severe
trauma to his left hand from a piece of
farm machinery. This patient was
referred to the Department of Surgery
at the Robert C. Byrd Health Sciences
Center of West Virginia University in
Morgantown one month later, with an
infected wound on the dorsal aspect of
the third and fourth digits, comminuted
fractures of the proximal and middle
phalanges, bone loss and damage to
the proximal interphalangeal joints and
extensor tendons (Figure 2a).

Debridement was performed,
eliminating all necrotic tissue and the
skin coverage was secured with a left
groin flap (Figures 2b, 2c). To maintain
finger length, a 3 cm. x 1 cm. cancelous

bone graft was transplanted to each
digit, obtained from the left ulna. An
external fixator was utilized to allow
the integration of the bone graft and
early mobilization of adjacent joints.
Offset pins were introduced at the base
of the proximal phalanx and at the
head of the middle phalanx to properly
attach the external fixator (Figures 2d,
2e). The device was removed after two
months and the patient regained good
function (Figures 2f, 2g).

Second case

A 30-year-old man sustained a chain
saw injury to the volar aspect of his left
thumb, presenting to the Emergency
Room at Ruby Memorial Hospital with
an incomplete amputation at the level
of the interphalangeal joint. The patient
was subjected to debridement of the
wound, immobilization of the fracture
with an external fixator (Figure 3a),
microanastomosis of one digitalartery,
repair of both digital nerves and
tenorraphy of the flexor policis longus.

Figure 1. External fixator applied to an experimental model.

Figure 2A. An open comminuted fracture of
the proximal and middle phalanx of the
left hand of a 15-year-old male patient
injured in a farm accident. Skin avulsion
and infection are present.

54 THE WEST VIRGINIA MEDICAL JOURNAL

Figure 2E. Skeletal stabilization with the external fixator.

Figures 2F and G. (Above and below) Appearance and function of
third and fourth digits of the left hand eight months after injury.

Figure 2C. Flap ready for transection of the pedicles at three weeks,
and bone alignment maintained with intramedullary K wires.

Figure 2D. Bone grafting and placement of offset pins.

The skin coverage became necrotic, exposing the flexor
tendon (Figure 3b), requiring coverage which was
transposed from the dorsum of the index finger (Figures
3c, 3d). The external fixator was removed in one month
after consolidation of the fracture after the patient retained
good function of the thumb (Figure 3e).

Third case

A 24-year-old man injured the fifth finger of his right
hand in an industrial accident. He sustained a closed
fracture at the base of the proximal phalanx and partial
amputation of the distal phalanx (Figure 4a). -

Figure 2B. Site for a split groin flap for wound coverage.

FEBRUARY 1994, VOL. 90 55

Figure 3A. Stabilization of a fracture of the distal phalanx and
interphalangeal joint of the right thumb of a 30-year-old man
injured with a chain saw.

Figure 3D. Flap insertion.

Figure 3B. Skin necrosis and exposure of the flexor policis tendon
two weeks alter injury.

Figure 3C. Transposition of a dorsal skin flap.

After reduction of the fracture, an external fixator was
applied for the purpose of stabilizing the fragments and
allowing early mobilization of adjacent joints (Figures 4b,

Figure 3E. Appearance of the distal phalanx and interphalangeal
joint after treatment and demondtration of gripping ability.

4c). The device was removed after three weeks with
normal function restored.

Operative technique

Under regional or axillary block anesthesia, one or two
offset pins are inserted into each bony fragment. To avoid
damage to the extensor tendon in a closed fracture, the
skin is perforated first and the tendon is pushed aside by
the tip of the pin.

Using a slow-speed power drill, the pins are inserted
through the dorsal cortical and medullary bone up to the
volar cortical bone, thus, avoiding damage to flexor
tendons and neurovascular bundles. The pins are
introduced transversely at a 90 degree angle to the long
axis of the bone because the small diameters of the bones
demand a meticulous insertion technique.

The fracture is then reduced by applying traction to the
finger and mobilizing the proximal and distal fragments
by external pressure. The fixator frame is assembled with
pin holders, vises and connecting rods. Radiograms are
used to assure proper alignment and to visualize the
placement of the pin in small fragments. In an open
fracture, the pins are placed to avoid wounds or
contamination of the tissue (1).

56 THE WEST VIRGINIA MEDICAL JOURNAL

Figure 4A. X-ray of a 24-year-old man showing an unstable closed
fracture to the left fifth digit of the proximal phalanx and partial
amputation of the finger tip after an industrial accident.

Figure 4B. Reduction and external fixation with two offset pins.

The wound and the sites of pin insertion are cleaned
every day with mild soap. Antibiotic ointment is applied
and the area covered with a sterile dressing. The patient is
examined every fifth day to assure stability of the
immobilization and to make necessary adjustments on the
fixator.

Radiographic controls will be taken after one or two
weeks and before removal of the frame. After a variable
period of two to eight weeks, depending on the severity7
of the fracture or bony grafting, the device is partially
disassembled and, if union is clinically evident, the device
is withdrawn with local anesthesia.

Discussion

The method of external fixation widely7 used in the
lower extremities (2) can now be readily utilized in
complex hand injuries. In addition, internal fixation with
K wires or micro plates and micro screws are good
methods of stabilizing phalangeal fractures (3)- However,
if there is soft tissue compromise or bone loss they may
not be the preferred method of treatment.

The primary indication for external fixation is the need
for stability and alignment of fractures in which early
mobilization of adjacent joints is necessary, and in
fractures with bone loss that cannot be internally fixed
(4). Anatomic restoration of the skeleton with stability

Figure 4C. Digit in good alignment.

allows joint motion and tendon excursion. Adequate
control of small bony fragments is obtained where in-line
pin placement is impossible in open fractures. The pins
can be placed to avoid wounds or contaminate tissue,
with a minimum of soft tissue dissection (5,6).

Temporary external fixation can be used for fracture
management until wound condition permits the
application of other means of osteosynthesis. The bones
can be manipulated with compression of the fracture to
create a gain in length or to hasten a delayed union.

Postoperative care requires strict compliance by the
patient, involving elevation of the extremity and
immediate active mobilization of the hand and fingers.

Pin infections have been reported and may require
antibiotic therapy and pin removal (5).

In 1974, Crockett (1) first described the technique of
external fixation using K-wires bonded with methyl
methacrylate resin. Several external fixation systems
designed specifically for small bone injuries are
commercially available. They present great versatility and
the components are designed so that the fracture can be
reduced after the frame is assembled, thus providing a
high degree of control over the exact positioning of small
bones (7).

Expertise in this method requires the surgeon to
become familiar with the device and its assembly (8). The
use of a skeletal model, where different types of fractures
can be reproduced and immobilized with the external
fixator, is of extreme value in training.

The method of external fixation provides a safe
approach in selected cases when other means of fixation
are inadequate.

References

1. Crockett DJ. Rigid fixation of bones of the hand using K wires
bonded with acrylic resin. The Hand 1974;6:106.

2. Vasconez HC, Nicholls PJ. Management of extremity injuries with
external fixator or Illizarov devices. Clin Plast Surg 1991;18:505.

3. Lamb DW, Abernethy PA, Raine PAM. Unstable fractures of the
metacarpals. The Hand 1973;5:43.

4. Freeland A. External fixation for skeletal stabilization of severe open
fractures of the hand. Clin Orthop 1987;214:93.

5. Parsons SW, Fitzgerald JAW, Shearer JR. External fixation of unstable
metacarpal and phalangeal fractures. J Hand Surg 1992;17B:151.

6. Pritsch M, Engel J, Farin I. Manipulation and external fixation of
metacarpal fractures. J Bone Joint Surg Am 1981;63A:1289.

7. Shehadi S. External fixation of metacarpal and phalangeal fractures. J
Hand Surg 1991;l6A:544.

8. Aro HT, Hein TJ, Chao EYS. Mechanical characteristics of an upper-
extremity external fixator. Clin Orthop 1990;253:240.

FEBRUARY 1994, VOL. 90 57

Rational treatment for dyslipidemias

ELLEN M. VERZINO, Pharm.D.

Pharmacy Practice Resident, Charleston Area
Medical Center, Charleston, W. Va
BARBARA KAPLAN, Pharm.D.

Assistant Professor of Clinical Pharmacy, West
Virginia University School of Pharmacy, and
Clinical Assistant Professor of Family
Medicine, West Virginia University School of
Medicine, Robert C. Byrd Health Sciences
Center of West Virginia University, Charleston
Division, Charleston, W.Va.

Abstract

High blood cholesterol is one of
the three most common risk factors
for cardiovascular disease. Several
antihyperlipidemic agents are
available to the prescriber; hoivever,
first line therapy is a diet low in
cholesterol and saturated fats. Tlje
choice of therapy must be based on
the type of abnormality present,
concurrent disease states, side effect
profiles, ease of use and cost. Several
differences exist among the various
dyslipidemic agents such as
mechanism of action, effectiveness,
pharmacokinetics, side effects, drug
interactions and cost. For these
reasons, this review focuses on the
most commonly used dyslipidemic
agents, e.g. the bile-acid sequestrants,
nicotinic acid, fibric-acid derivatives
and HMG-CoA reductase inhibitors.

Introduction

Cardiovascular disease (CVD) is one
of the major causes of mortality in the
United States, accounting for almost
one in every two deaths. This is true
even though deaths from heart attacks
and strokes have decreased since the
early 1970s. Yet, more than 4 million
Americans have experienced a heart
attack or stroke that has compromised
their quality of life (1).

Three major risk factors for CVD are
smoking, high blood pressure and
high blood cholesterol. Other risks
include obesity, diabetes, family history,
reduced high density lipoprotein
(HDL) cholesterol (< 35mg./dL), and
male gender (1). Although many of
the risk factors cannot be modified,
studies have shown that lowering
cholesterol levels decreases the
chance of experiencing a major
cardiac event (2).

The National Cholesterol Education
Program (NCEP) established
guidelines based on levels of total
cholesterol and low density
lipoprotein (LDL) cholesterol for the
diagnosis and treatment of high blood
cholesterol in adults. LDL is the
primary target for cholesterol-lowering
strategies, and low HDL is also a risk
factor for CVD (2). The NCEP
recommends that patients should be
initially treated with exercise, diet, and
weight reduction (3). Many patients
can be controlled using this regimen
alone, but some may need drug
therapy. There are several different
drugs available for treating
dyslipidemias, and each has a
particular indication. Table 1 lists the
agents currently available for the
treatment of hyperlipidemia.

There are five types of dyslipidemias
based on elevations of cholesterol,
triglycerides, or both, and defects in
lipoproteins (4). They are as follows:

Type I Very high triglycerides

Type Ila High cholesterol

Type lib High cholesterol and
triglycerides (LDL and
VLDL elevated)

Type III High cholesterol and

triglycerides (intermediate
density lipoprotein
elevated)

Type IV High triglycerides and
normal to slightly high
cholesterol

Type V Very high triglycerides
and cholesterol

Although probucol (Lorelco®) and
dextrothyroxine (Choloxin®) have
been listed in Table 1 for completeness,
they will not be included in this

discussion. These medications are
seldom used since the advent of
newer treatments. Thus, this
discussion will focus on the bile acid
sequestrants, nicotinic acid, fibric acid
derivatives and the 3-hydroxy-3-
methylglutaryl coenzyme A (HMG-
CoA) reductase inhibitors.

Bile-acid sequestrants

Mechanism of action

Cholesterol is the major precursor of
bile acids which are secreted via the
bile from the liver and gall bladder
during normal digestion. In the
intestines, bile acids emulsify the fat
and lipid materials in food, thus
facilitating absorption. The bile-acid
sequestrants, cholestyramine
(Questran®) and colestipol
(Colestid®), lower cholesterol by
binding with bile acid in the
intestines. Subsequently, an insoluble
complex is formed which is then
excreted in the feces. Thus, a partial
removal of bile acids from the
enterohepatic circulation occurs,
preventing absorption.

Bile acid sequestrants cause an
increase in hepatic cholesterol
synthesis, but the plasma cholesterol
levels decrease secondary to an
increased rate of clearance of
cholesterol-rich lipoproteins from the
plasma. In addition, serum triglyceride
(TG) levels may increase by 5 percent
to 20 percent in the first few weeks of
therapy; however, TG levels will return
to pretreatment values within four
weeks of discontinuing treatment.

Pharmacokinetics

Bile-acid sequestrants (anion
exchange resins) are hydrophilic, but
insoluble in water. Systemic absorption
does not occur because these agents
remain unchanged in the GI tract.

TABLE 1. Agents for hyperlipidemia

Bile Acid Sequestrants

HMG-CoA Reductase Inhibitors

- cholestyramine

- lovastatin

- colestipol

- pravastatin

- simvastatin

Nicotinic Acid

Probucol

Fibric Acid Derivatives

Dextrothyroxine

- gemfibrozil

- clofibrate

38 THE WEST VIRGINIA MEDICAL JOURNAL

LDL cholesterol (LDL-C) levels will
begin to decrease within four to seven
days of treatment, resulting in a total
reduction in LDL cholesterol of 20
percent. The response to treatment is
usually evident after one month of
therapy. Consequently, upon
discontinuation of therapy,
pretreatment LDL-C levels return after
one month.

Effectiveness

In Type Ila hyperlipoproteinemia,
colestipol is more effective than
clofibrate in lowering total and LDL-C,
with no effect on HDL-C. If optimal
response to colestipol alone is not
achieved, especially in heterozygous
familial hypercholesterolemia, the
addition of nicotinic acid (Niacin) will
effectively lower serum cholesterol,
TG, and LDL-C, while increasing
HDL-C significantly. Further results at
lowering cholesterol levels have been
achieved with the bile sequestrants
and lovastatin (Mevacor®).

Studies have shown a reduction in
the rate of CHD death and non-fatal
MI with administration of bile-acid
sequestrants. In a large, multiclinic
study, a 19 percent reduction in the
combined rate of CHD death plus
non-fatal MI (cumulative incidences of
7 percent cholestyramine and 8.6
percent placebo) was seen during a
7-year study period. Subjects were
middle-aged males (ages 35 to 59)
with serum cholesterol levels greater
than 265 mg./dl. and no previous
history of heart disease.

Side effects

Constipation is the most common
adverse effect. This can occur in up to
10% of patients and at times can be
severe, leading to fecal impaction.

Other gastrointestinal effects are
less common, e.g. abdominal pain,
bloating, flatulence, nausea, vomiting,
indigestion, and diarrhea.
Hyperchloremic acidosis and
increased urinary calcium excretion
may also occur.

Drug interactions

The bile acid sequestrants may
delay or reduce the absorption of
concomitant oral medications by
binding to drugs in the GI tract. To
avoid decreased absorption, separate
other medications from the bile-acid
sequestrants by one hour before a
dose or four to six hours after a dose.

Dosing times are most critical with
drugs having a narrow therapeutic
index, such as warfarin (Coumadin®),
digoxin (Lanoxin®), thyroid hormones,
and corticosteriods. Other agents to

consider include acetaminophen
(Tylenol®), naproxen (Naprosyn®),
piroxicam (Feldene®), propranolol
(Inderal®), thiazide diuretics, and
ursodiol (Actigall®). Malabsorption of
the fat-soluble vitamins (A,D,E, and K)
can occur with these agents, especially
when given for prolonged periods of
time. Supplementation with water-
miscible (or parenteral) forms of
vitamins A and D may be required.

Administration

The lipid-lowering effect of 4 g.
cholestyramine equals 5 g. colestipol.
Adult doses should be individualized
and although generally given three to
four times daily, no apparent
advantage is seen from dosing these
agents more than twice daily (Table 2).
Patients should be told to take these
medications before meals, mixing them
with beverages, highly fluid soups,
cereals or pulpy fruits.

Nicotinic acid

Mechanism of action

Nicotinic acid or niacin is a B
vitamin. Although the exact mechanism
of action of lipid lowering is unknown,
nicotinic acid inhibits lipolysis in
adipose tissue, decreases esterification
of triglyceride in the liver and
increases lipoprotein lipase activity.

Effectiveness

At doses of 3 to 6 grams daily,
nicotinic acid reduces LDL and VLDL

cholesterol and TG by 20 to 40 percent
in 1 to 7 days; maximal effect on LDL
is seen after three to five weeks of
therapy. HDL-C is increased by 20
percent (6).

Pharmacokinetics

Nicotinic acid is rapidly and nearly
completely absorbed in the intestines.
Peak plasma levels are reached in 45
minutes. Renal excretion predominates;
urinary excretion of a 3 g. dose is 88
percent.

Side effects

Adverse effects are predominantly
dose-related with the most common
being gastrointestinal upset, flushing,
and pruritus. Flushing occurs within
20 minutes of administration and may
last for 30-60 minutes. The frequency
and severity generally subside with
continued therapy. One 325 mg. tablet
of aspirin may reduce the incidence of
flushing.

Although extended-release products
of niacin are available, they have not
been shown to cause less flushing,
and they can be associated with more
GI side effects. Niacin has also been
found to cause glucose intolerance
and liver toxicity, therefore it is not
the drug of choice in diabetic patients,
and periodic liver function tests need
to be performed.

Administration

To reduce the incidence of side
effects, niacin should be given in low,
divided doses on a full stomach or with

Table 2. Summary of antihyperlipidemic agents, doses and costs

Generic Name

Brand Name

Dose

Cost*

Effect

Cholestyramine

Questran

4 g. given 1-6

$22.80-$ 136.80

«fTG, l LDL

Questran

times/day

$22.804136.80

«-+HDL, 4-TC

Light

$33.364 200.16

Cholybar

Colestipol

Colestid

5-30 g. QD or in

$20.784124.70

<-*fTG, iLDL

divided doses

•^HDL, 4.TC

Nicotinic Acid

Niacin

1-2 g. TID with

$11.07422.14

4-TG, |LDL

meals

^HDL, 4TC

Gemfibrozil

Lopid

600 mg. BID

$60.20

4-TG, <~nLDL

taken 30 minutes

^HDL, 4-TC

before meals

Lovastatin

Mevacor

20-80 mg./day

$55.304199.03

--4.TG, .TDL

in single or

<-tHDL,4.TC

divided doses

Pravastatin

Pravachol

10-40 mg.

$47.11499.83

<->!TG, +LDL

bedtime

<->1'HDL, 4.TC

Simvastatin

Zocor

5-40 mg./day in

$47.244140.97

•^^TG, 4LDL

the evening

<->tHDL, FTC

* Cost for 30 days of therapy according to AWP listing in Redbook 1993

(priced from lowest to highest dose per day)

^ = increase

LDL

= low density lipoprotein

TID = three times daily

+-» = unchanged

HDL

= high density lipoproteir

BID = twice daily

+ = decrease

TC =

total cholesterol

TG = triglyceride

QD =

once daily

FEBRUARY 1994, VOL. 90 59

antacids. In addition, doses should be
titrated gradually, starting with 1 to 2 g.
per day given in divided doses, three
times per day with a maximum daily
dose of 8 g. Substantial effects on LDL,
TG, and HDL are usually seen with
doses of 3 to 6 g. daily (3).

Fibric-acid derivatives

Mechanism of action

The mechanism by which the fibric-
acid derivatives work has not been
definitely established. Gemfibrozil
(Lopid®) appears to inhibit peripheral
lipolysis and decrease hepatic
extraction of free fatty acids, thereby
reducing hepatic TG production.

Effectiveness

In the Helsinki Heart Study,
treatment with gemfibrozil resulted in
a 34% decrease in serious coronary
events and a 37% decrease in non-fatal
MI (7). Greatest reductions occurred in
patients with both elevated LDL-C and
triglycerides.

Pharmacokinetics

Both agents are well absorbed and
the onset of action is two to five days.
These agents are largely renally
eliminated so that decreased doses may
be needed in those with decreased
renal function, although specific doses
have not been recommended.

Side effects

Adverse reactions which occur with
these agents include dyspepsia (19.6%),
abdominal pain (9.8%), diarrhea (7.2%),
nausea/vomiting (2.5%), fatigue (3-8%),
vertigo (1.5%), headache (1.2%), and
eczema (1.9%). Administration may
also lead to gallstone formation and
should be discontinued if this occurs.

Although transient liver function
abnormalities (increased transaminase,
creatine phosphokinase, lactic
dehydrogenase, bilirubin and alkaline
phosphatase) may occur, they are
usually reversible upon drug
discontinuation. Nevertheless, periodic
(annual) liver function studies should
be monitored and therapy should be
discontinued if abnormalities persist.

Drug interactions

Clofibrate and gemfibrozil may
potentiate the anticoagulant effects of
oral anticoagulants (e.g. warfarin), so
the prothrombin time should be
closely monitored. Appropriate dose
adjustments should be made during,
and for several days following the
initiation of concomitant therapy, until
prothrombin time has stabilized.

In addition, gemfibrozil should not

be used with lovastatin due to an
increased risk of severe myopathy,
rhabdomyolysis and acute renal
failure (5).

Administration

Gemfibrozil should be administered
30 minutes before the morning and
evening meals (Table 2). Therapy
should be withdrawn if no response
has occurred after three months of
therapy.

The manufacturer recommends that
clofibrate be taken with food to
minimize stomach upset.

HMG-CoA reductase inhibitors

Mechanism of action

Lovastatin (Mevacor®), pravastatin
(Pravachol®), and simvastatin (Zocor®)
lower total and LDL-C by inhibiting the
enzyme HMG-CoA reductase. This
enzyme converts HMG-CoA to
mevalonate, which is an early and
rate-limiting step in cholesterol
biosynthesis (8).

Effectiveness

There are only a few studies which
have compared these agents;
therefore, it is difficult to determine
whether any of these medications are
more effective or safer than the others
(8). Long-term studies have yet to
establish the effects of these agents on
cardiovascular morbidity and mortality.

As monotherapy, the HMG-CoA
reductase inhibitors are the most potent
total and LDL cholesterol-lowering
agents and are usually the best
tolerated (9).

Pharmacokinetics

All of these agents undergo
extensive first-pass extraction by the

liver. Lovastatin and simvastatin are
both extensively bound to protein,
while pravastatin is only 50% bound.

Pravastatin is active when given
orally, whereas, lovastatin and
simvastatin are prodrugs and need to
be hydrolyzed to their active forms.
Plasma concentrations of lovastatin
are significantly decreased when given
on an empty stomach. Pravastatin and
simvastatin are not effected by the
presence or absence of food in the
stomach.

All three agents are eliminated by
both the fecal and renal route; however,
the fecal route predominates (8).

Side effects

Concurrent administration of
gemfibrozil and lovastatin has produced
myopathies and rhabdomyolysis. This
may also occur with pravastatin and
simvastatin, so the concomitant use of
these agents with gemfibrozil, niacin,
erythromycin, and immunosuppressants
should be carefully monitored (8). In
addition, concurrent use of digoxin
and simvastatin may lead to slight
elevations in serum digoxin levels.

Lovastatin and simvastatin have
been shown to increase the effects of
warfarin, but this has not been
reported with pravastatin, but
precautions should be taken when
using any HMG-CoA reductase
inhibitor with warfarin. These agents
also cause transient elevation of liver
transaminases, so periodic liver
function tests should be performed.

Lovastatin has been reported to
cause lens opacities, blurred vision,
insomnia, and impotence (TO).
Pravastatin has been reported to cause
blurred vision but not insomnia or
impotence (11), and simvastatin has not

Table 3- Effects and precautions of anti-hyperlipidemic agents

Drue Name

Reduce CHD?

Long-Term

Safetv

LDL-C

Decrease

Soecial Precautions

Cholestyramine

yes

15-30%

Increase TG

Colestipol

yes

15-30%

Increase TG

Nicotinic Acid

yes

15-30%

Test for hyperuricemia
hyperglycemia, and
LFTs

Lovastatin

not proven

not established

25-45%

Monitor LFTs

Pravastatin

not proven

not established

25-45%

Monitor LFTs

Simvastatin

not proven

not established

25-45%

Monitor LFTs

Gemfibrozil

yes

preliminary

evidence

5-15%

May increase LDL-C
in hypertriglyceride
patients; don't use in
those with gallbladder
disease, monitor LFTs

* CHD = coronary

heart disease

TG =

triglyceride

LDL-C = low density lipoprotein cholesterol LFTs = liver function tests

60 THE WEST VIRGINIA MEDICAL JOURNAL

Table 4. Anti-hyperlipidemic agents for the major classes of hyperlipidemia (4)

Tvpe of Hvperlipidemia

Aeents Indicated

Hypercholesterolemia alone

Bile acid sequestrants
Nicotinic acid

HMG-CoA reductase inhibitors

Hypertriglyceridemia alone

Nicotinic acid

Fibric acid derivatives (gemfibrozil)

LDL-C and hypertriglyceridemia

Nicotinic acid

HMG-CoA reductase inhibitors
Fibric acid derivatives (gemfibrozil)

LDL-C = low density lipoprotein cholesterol; HMG-CoA = 3-hydroxy-3-methylglutaryl coenzyme A

been reported to cause any of these
three side effects (12). Since lovastatin
has been available for a longer period
of time, one should still monitor
patients for similar side effects when
prescribing pravastatin and simvastatin.

Administration

Lovastatin should be given with
meals at doses of 20 to 80 mg. per
day in single or divided doses.
Pravastatin and simvastatin can be
given once daily without regard to
meals (Table 2).

In addition, patients with significant
renal or hepatic dysfunction and the
elderly should be started at one-half
of the usual initial dose for all of
HMG-CoA reductase inhibitors
(10-12).

Conclusions

Today, there are many effective
agents for treating hyperlipidemia.

Although first line therapy is a diet
low in cholesterol and saturated fats, a
rational approach to drug therapy is
required when diet therapy fails. The
choice of an agent should be based
on the type of abnormality present,
concurrent disease states, and side
effects.

Combination drug therapy should
be considered only after compliance
with a single-drug regimen has been
documented. The most effective
combination for reducing total
cholesterol and LDL cholesterol are the
HMG-CoA reductase inhibitors with a
bile-acid sequestrant or niacin with a
bile-acid sequestrant.

Tables 2-4 illustrate comparisons of
the various agents for hyperlipidemia.
It is important to remember therapy
should be initiated only after
secondary causes have been ruled out
and diet therapy has failed.

References

1. National Heart, Lung and Blood Institute’s
(NHLBI) Report of the Task Force on
Research in Atherosclerosis, U. F. Department.
H. H. S., Public Health Services, September
1991.

2. Expert Panel. Report of the National
Cholesterol Education Program Expert Panel
on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. Arch
Intern Med 1988;148:36-9.

3. Davidson M, Rosenson R, Massone T. From
diagnosis to treatment: focus on costs,
safety, and efficacy of antihyperlipidemic
agents. Hosp Formul 1993;28:262-82.

4. Gotto A, Pownall H. Dietary and drug
therapy of hyperlipidemia. In: Witthauer
MF, editors. Manual of Lipid Disorders.
Baltimore: Williams & Wilkins, 1992.

5. The Lipid Research Clinics Investigators.

The lipid research clinics coronary primary
prevention trial: results of 6 years of post-
trial follow-up. Arch Intern Med 1992,152:
1399-1410.

6. Carlson LA, Hamster A, Asplund A.
Pronounced lowering of serum levels of
lipoprotein Lp (a) in hyperlipidaemic
subjects treated with nicotinic acid. J Intern
Med 1989;226:271-6.

7. Mannenen V, Olli Elo M, Heikki Frick M, et
al. Lipid alterations and decline in the
incidence of coronary heart disease in the
Helsinki Heart Study. JAMA 1988;260:64l-
51.

8. Colosimo R, Nunn-Thompson C. HMG-CoA
reductase inhibitors. P & T 1993 (Jan):21-24,
29-30,65.

9. Jungnickel P, Cantral K, Maloley P.
Pravastatin: a new drug for the treatment of
hypercholesterolemia. Clin Pharm 1992;11:
677-89.

10. Mevacor Product Information. Merck Sharp
& Dohme. Westpoint (PA) 1992.

11. Pravachol Product Information. Bristol
Myers Squibb. Princeton (NJ) 1991.

12. Zocor Product Information. Merck Sharp &
Dohme. Westpoint (PA) 1992

Manuscript Guidelines

All scientific manuscripts should be submitted on an IBM
compatible disc in Wordperfect 5.1 or in ASCII (generic). They
must be prepared in accordance with “Uniform Requirements
for Manuscripts Submitted to Biomedical Journals. ”

All manuscripts should include:

1. Title page

2. An abstract of no more than 150 words

3. Text

4. Acknowledgements

5. References in parentheses numbered consecutively. No
more than 25 references will be published free of charge.

6. Tables

7. Legends for illustrations

All persons designated as authors should qualify for
authorship. Each author should have participated sufficiently
in the work to take public responsibility for the concept.

Where reference is made to generically-designated drugs,
the first such reference must be followed by parentheses
containing its most commonly known trade name.

All scientific material is reviewed by the Publication
Committee and should be sent to The Editor, West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.

FEBRUARY 1994, VOL. 90 6l

Contact Nd:YAG laser excision of rhinophyma

ROMEO Y. LIM, M.D., F.A.C.S.

Chief of Surgery, The Eye and Ear Clinic of
Charleston ; Chief of the Department of
Otolaryngology, Charleston Area Medical
Center; and Clinical Professor of
Otolaryngology/Head and Neck Surgery
and General Surgery, Robert C. Byrd Health
Sciences Center of West Virginia University,
Charleston Division, Charleston, W. Va.

Abstract

Rhinophyma, an excessive
hyperplasia of the sebaceous glands
of the nose, results in disfigurement,
occasional nasal blockage and
recurrent infection. This condition is
considered to be the culmination of
acne rosacea and can degenerate to
a basal cell or squamous cell
carcinoma (1 ). Various surgical
methods have been used to treat
rhinophyma, but most have resulted
in complications and poor cosmetic
outcomes. Wenig and Weingarten (6)
reported four cases of rhinophyma
which were successfully treated with
the contact Nd YAG laser, and this
article describes my experience in
use of this modality to treat a
71 -year-old patient at the Eye and
Ear Clinic of Charleston.

Introduction

Rhinophyma was described by
Hebra in 1845 as an excessive
hyperplasia of the sebaceous glands of
the nose resulting in disfigurement,

occasional nasal blockage and
recurrent infection. It is a slow
overgrowth with uncertain etiology
and unrelated to alcohol intake.
Rhinophyma is considered to be the
culmination of acne rosacea and can
degenerate to a basal cell or squamous
cell carcinoma (1).

Treatment of rhinophmya is surgical
and classified as complete excision
with skin grafting and controlled
excision with secondary epithelial
regeneration (2). Various surgical
methods such as cryosurgery,
electrocautery, dermabrasion (3), and
non-contact laser therapy (4,5) have
been used for rhinophyma with high
instances of complications and poor
cosmetic results. Wenig and Weingarten
reported four cases of rhinophyma
which were successfully treated with
the contact Nd:YAG laser (6).

The SLT contact Nd:YAG laser
system, which was developed by
Surgical Laser Technologies in Oakes,
Pa., has been used since 1988 in 90%
of the head and neck procedures at
the Eye and Ear Clinic of Charleston
because of its precision, controllability,
atraumaticity, facility, hemostasis, and
acicatrization (7).

Case report

A 71 -year-old white man was
referred by a dermatologist for a
growth which had been on his nose
for five years. This growth was
associated with an oozing of sebum
and painful intermittent infection. The

patient was taking an anticoagulant
due to a previous history of stroke.
Examination disclosed an exuberant
overgrowth of sebaceous glands of the
entire external nose with partial
blockage of the nares (Figure 1).
Punctate areas of sebum were
observed and the diagnosis was
rhinophyma.

Technique

Under propofol (Diprivan)
intravenous analgesia, the bulk of the
rhinophyma was excised using a
contact Nd:YAG laser 0.6 mm. frosted
sapphire scalpel screwed onto a
general handpiece set at 12 watts
continuous mode. As shown in Figure
2, the light touch technique was
utilized for effective and atraumatic
tissue excision. Areas of residual
rhinophyma were polished in a
brushing manner with a vaporizing
probe. Preservation of normal
anatomy, especially of the alar area is
mandatory to prevent contracture and
notching. Sebaceous materials crackled
under vaporization and constant
suctioning was required to remove
odor and smoke. Minimal bleeding
was observed with this technique.

After completion of the excision, the
wound was covered with collagen pad
dressing impregnated with Chloro-
elase ointment. The dressing was
changed weekly till complete epithelial
regeneration was achieved in 12
weeks. Retouching with a vaporizing
probe was done at two-month

Figure 1. Exuberant rhinophyma.

Figure 2. Use of the contact Nd:YAG laser.

62 THE WEST VIRGINIA MEDICAL JOURNAL

Figure 4. Complete healing in 12 weeks.

intervals for rhinophyma residues.
Crusting persisted for eight weeks and
it was managed with hydrogen
peroxide cleansing and Chloro-elase
ointment collagen pad application
(Figure 3). No complications arose
during a six-month follow-up with
excellent functional and cosmetic
results (Figure 4).

Discussion

The contact Nd:YAG laser sapphire
probes, which were developed by
Daikuzono (8) in 1985, provide a
versatile cutting and coagulating tool
with precision, controlled tissue
penetration (0.5 mm.), concentrated
power density and minimal tissue
injury. In the non-contact mode, more
tissue damage and necrosis ensue
because of higher power output
requirement and uncontrolled
scattering. The contact Nd:YAG laser
probes are applied directly to tissues
so the surgeon is afforded a tactile
feedback and focusing is not required.
It can coagulate blood vessels of one

mm. diameter, creating a bloodless
field.

Compared to the CCL laser, the
contact Nd:YAG laser system is less
cumbersome, more precise and more
effective because it can cut in the
presence of fluid. It also creates less
fumes, less tissue damage, and
promotes prompt healing and reduced
operating time.

Conclusion

Conventional methods of
rhinophyma surgery are fraught with
excessive bleeding, imprecise excision
and poor healing with unsatisfactory
cosmetic results. At this time, the
contact Nd:YAG laser is the best tool
for surgery of rhinophyma because of
its ability to cut accurately, as well as
promote efficient coagulation and
prompt healing.

References

1. Broadbent NRG, Cort DF. Squamous

carcinoma in long-standing rhinophyma. Br J

Plast Surg 1977;30:308-9.

2. Staindl O. Surgical management of rhinophyma.
Acta Otolaryngologica 1981;92:137-40.

3. Farrior RT. Dermabrasion in facial surgery.
Laryngoscope 1985;95:534-45.

4. Shapshay SM, Strong MS, Guspar WA, et al.
Removal of rhinophyma with carbon dioxide
laser. Arch Otolaryngol Head Neck Surg
1980;106:257-9.

5. Wheeland RG, Bailin RL, Ratz RL. Combined
carbon dioxide laser excision and
vaporization in the treatment of rhinophyma.
J Dermatol Surg 1987;13:172-7.

6. Wenig BL, Weingarten RT. Excision of
rhinophyma with Nd:YAG laser: a new
technique. Laryngoscope 1993;103:101-3.

7. Lim RY, Willis MJ. Contact Nd:YAG laser for
soft tissue surgery. W Va Med J 1991;87:246-9-

8. Daikuzono N. Contact delivery systems and
accessories. In: Joffee S, Oguro Y, editors.
Advances in Nd:YAG laser surgery. New
York: Springer-Velag, 1988:19-29-

Acknowledgements

The author wishes to thank Mary
Jane Willis, P.A., for assisting in
preparation of the manuscript, and
Elaine Young, M.D., for the case
referral.

FEBRUARY 1994, VOL. 90 63

As we move towards health system
reform, it seems as though we
keep taking steps backwards. I’m sure
you’re very familiar with a few of
these steps which the federal
government obviously deems as
progress.

Take for example CLIA. This
legislation will certainly clean up the
physician office lab problem. (Was
there a problem?) In fact, now there
are so many tons of paperwork, so
many duplicate records to keep, and
so many other hassles that office labs
will probably cease to exist.

And what about Medicare? This
efficiently designed system now
makes you bill separately for durable
medical equipment provided in your
office. The goal of this ridiculous
practice, as one Medicare official
stated it, is to have physicians include
the DME in the global fee or simply
not offer this service to avoid the
hassle. Great cost containment.

Most of us realize that regulations
such as CLIA and separate billing for
durable medical equipment only make
delivery of medical care more difficult,
and we must continue to show how
these measures reduce access to
care for our patients. It is very
questionable as to whether these
regulations are designed to control
cost or access.

President's Page

2).

Tinkering with the equation
for access

Speaking of access, many stabs are
taken at solving this problem by
suggesting that any access problem
can be solved by increasing the
number of primary care physicians
and mid-level practitioners (PAs and
nurse practitioners). While this may
increase access at first, we must also
look at the long-term effect and
proceed with caution.

Increasing the number of primary
care physicians at the risk of
reduction in our pool of specialists
may slow the enormous advances in
medical care that we have come to
expect. Incentives for rural practice
and residency quotas may discourage
students from choosing the fields they
are most interested in pursuing.
Forcing students into molds, whether
they are doctors or engineers, will
only make unhappy professionals.
Encouraging primary care is a good
option and finding ways to make rural
practice rewarding and financially
feasible will ultimately produce better
results.

The puzzle of access to medical
care has so many angles that at times
it seems unsolvable. In fact, I might
agree that access to medical care for
most Americans is not a problem. We
must admit that for some, access to
medical care beyond basic, acute or
emergency care, is a problem because

of cost. Some people may choose to
be in this financial situation, but
others have no choice.

It is critical that we offer solutions
to the problem of access very
carefully because unlimited access to
medical care can be extremely costly.
It is obvious that we must look for
ways to control access or to make it
more efficient. A strong health care
team must be the basis for improving
the problems we may have with
access, and each team member must
recognize his or her role. Physicians
must accept their responsibilities as
leaders of the health care team and
improve team performance.

Nurse practitioners and physician
assistants are also vital parts of the
health care team, and we must
continue to find ways to work
together in collaborative arrangements
to deliver patient care. All too often,
however, it is argued by government
that nurse practitioners and physician
assistants can replace physicians.

Their training, though, is not the
same, and if their training is not equal
to that of physicians, the products will
always be much different.

We must work together to refine,
not replace our delivery system in
order to serve the best interests of our
patients.

James L. Comerci, M.D.

64 THE WEST VIRGINIA MEDICAL JOURNAL

Editorials

The Pitchmen

They must think that Alzheimer’s is
endemic in the Medicare crowd. How
else to account for the flapdoodle
directed by the Clinton administration
to the elderly?

The pitch is, “Our health care
reform will improve your Medicare
benefits! We will give you long-term
care and full therapeutic drug benefits
in addition to what you receive now.
On top of that, we will save $124
billion from what we presently are
paying for your care.”

Memories of a side-show barker
come to mind. “Yes, indeed folks. Just
step right up and see how we are
going to do all this through federal
government efficiency. Genuine
efficiency! No tricks. No gimmicks.

Just honest government efficiency . .

It doesn’t take a rocket scientist to
recognize this hoax. A genuine
Alzheimer’s sufferer might find it not
too difficult to fathom. The subject to
be avoided among the crowd by this
glib pitch is RATIONING.

I Of course, they can save $124
billion dollars. They can save more
than that if they have a mind to . . .
make the waiting list a little longer in
any of a number of surgical or
diagnostic procedures. Their thinking
goes, “It’s very expensive to keep

these old folks alive. So, a few of
them die waiting . . . they probably
would have died no matter what. Just
look at the nice effect it has on the
cost of medical care though. That’s
efficiency!”

Government efficiency! A prototypal
example of an oxymoron. Government
efficiency indeed! A bureaucracy
beyond anyone’s wildest nightmare is
what we will get.

Politicians love bureaucracies!
Bureaucratic employees are all voters
and they are beholden to those
legislators who create, maintain and
feed the bureaucracies. Once a
bureaucratic job has been created,
there is zero motivation to do away
with it ever — no matter the evidence
there might be that the job is not
needed, a needless expense, a
liability. It is a vote!

A recent example of government
efficiency at work is the Federal
Aviation Administration, the bureau in
charge of air traffic safety. The
airlines, those most affected, have
expressed unanimous agreement that
the FAA should be abolished. One
reason given is that it takes the FAA
so long to develop, approve and
purchase safety devices and
equipment that by the time the

equipment is installed, it is hopelessly
out of date. Can you translate such
government efficiency to medical care?

The administration seems to suggest
that the answer to the FAA problem is
the establishment of a government-
owned corporation along the lines of
AMTRAK. God help us! Especially all
those trusting and secure-feeling
airline passengers.

We can never afford to listen to liars
and con artists or those political
leaders whose political success is
based on lies and con artist
techniques. We particularly cannot
afford to listen to these hucksters as
they play a financial shell game with
medical care costs, medical care
availability and medical care quality.
Too much is at stake. The medical
care system is at stake. People’s health
and comfort, their very lives are at
stake.

When the quality of medical care is
diminished in any manner or the
availability of care is limited through
any form of rationing, millions are put
in mortal jeopardy.

It is time that something other than
dollars is talked about!

- Stephen D. Ward
Editor

Non-game wildlife programs

In February 1992, we first spoke
favorably about the West Virginia
non-game wildlife programs.
Permanent and adequate funding for
these programs is now being sought
by concerned groups who are
submitting legislation this session.

Environmental concerns promoted
in this effort have peculiar importance
for our state. West Virginia has few
things going for it aside from those

provided by the Lord through his
initial gift of nature’s kindest and best
assets. Our hills, valleys, streams,
wildlife, and the flora and fauna that
grace these hills are unmatched by
any other state.

If through neglect we allow our
state government to treat Nature the
way it treats business and professions,
West Virginia will soon become an
arid and lifeless wasteland.

We join with other concerned
groups in encouraging the West
Virginia Legislature to assure non-
game wildlife programs a steady,
predictable and assured source of
funding so that their important and
valued work can continue and grow.

- Stephen D. Ward
Editor

FEBRUARY 1994, VOL. 90 65

Special Correspondence

James Todd, M.D.

American Medical Association
515 North State Street
Chicago, IL 60610

Dear Dr. Todd:

I telephoned you last spring to express my concern to you that the AMA was not demanding more of a role
in shaping the future of health care. You reassured me.

As I have watched developments since then, I have become convinced that the Clinton plan boils down to
something very simple: big government control. To do this they plan to cap the amount of money going into
the system, and force physicians to do the rationing as best we can work it out among ourselves. This is
fundamentally unacceptable, but it becomes frankly intolerable with no meaningful tort reform and with the
government continuing to promise more than it can deliver.

It is indeed unfortunate that we have allowed such words as “crisis” and “reform” to dominate the discussion.
We have some problems with health care, but we certainly do not have a “crisis.” That is baloney! Moreover,
many (if not most) of the problems we do have can be traced to excess government intrusion, along with
manipulation of the marketplace by the government and by insurance companies.

Why does the AMA not advocate free market approaches such as medical savings accounts, etc., as proposed
by Senator Phil Gramm? That certainly makes more sense than prescribing an increased dose of the
governmental and bureaucratic poison that has already caused the illness.

Unless the American Medical Association promptly declares its total dissatisfaction with the Clinton plan, I
don’t believe it is adequately serving its membership, and it is certainly not serving the American public.

Sincerely yours,

Fred F. Holt, M.D.

cc: WVSMA AMA Delegates and others

Fred F. Holt, M.D.

3100 MacCorkle Avenue, SE
Charleston, West Virginia 25304

Dear Dr. Holt:

Thank you for taking the time to express your views to me and the American Medical Association (AMA)
regarding health system reform. The AMA believes that physicians and their representative organizations need
to be fully involved in development of health system reform. No one knows better than physicians the strengths
and weaknesses of our current system. Only by actively including the medical profession in the reform debate
will an appropriate balance of cost, quality, and choice be maintained.

The AMA seeks reform that is well-founded and retains the excellence of our present system, not reform that
is bureaucratic, centrally controlled, and steeped in governmental arrogance. We are willing to work with all
parties; we will keep a positive public image, but we must not proceed in a manner that would jeopardize the
patient-physician relationship, or the tradition of excellence of the medical profession.

During the past year, the AMA has been very actively involved with the White House Task Force on National
Health Care Reform, the Administration, and the Congress. We have advocated physicians’ views at numerous
meetings. But physicians are not the only group that has a stake in this issue. Many groups are "fed up” with
health care costs and want drastic action. Our job is to communicate, advocate, and educate, as best we can.
The AMA is working hard at that.

The AMA believes that this is just the beginning of a long campaign to achieve the best possible reform for
patients and physicians, and many ideas will be considered and debated as reform legislation is moved through
the Congress. I hope that you will take every opportunity to make your views known to members of your
community and your legislative representatives. By voicing your opinion, you can help shape the direction of
health system reform.

Thank you for taking the time to communicate your views. It is heartening to know that busy physicians care
enough to take the time to give attention to the impact of health system reform proposals. Thank you for your
membership in the AMA. Be assured that the AMA is working diligently. It is our hope that all physicians will
also lend their voices so that the best possible reforms are adopted.

Sincerely,

James S. Todd, M.D.

66 THE WEST VIRGINIA MEDICAL JOURNAL

Be on the inside
of health system ^
reform ^

Come to
Washington
on March 8 ^

Join us and make
a difference

Partnership in Action:
Uniting for America's
Health

When reform proposals take shape, will your views be
included? Specific health reform proposals are being
hammered into policy in our nation's capital. Now is the
time to ask questions and voice concerns.

The American Medical Association will host an interactive
meeting of key congressional policy makers and physicians
from across the country. Partnership in Action: Uniting for
America's Health takes place March 8 in Washington, DC.

March 8 will be a day filled with interactive dialogue
between policy makers and the physicians who will be
affected by those policies. Dinners will feature roundtable
discussions with congressional members from coast to coast.

Your presence at the 1994 summit can make a
difference. To register now, call 800 262-3211.

American Medical Association

Physicians dedicated to the health of America

Huntington site for 42nd WVAAFP assembly

Harris Gambrel! Hatfield

The 42nd Annual Scientific Assembly
of the West Virginia Chapter of the
American Academy of Family
Physicians is set for April 8-iO at the
Radisson Hotel in Huntington, with
special preconference events on
Thursday, April 7.

This year’s first preconference event
will be the 13th Annual Golf Tournament
at Lavalette Golf Club, which will tee
off at 11 a.m. on April 7. That
afternoon, a luncheon will be held
from 12:30 p.m. - 1:30 p.m., and then,

1 larold Preston, president of Physicians
Practice Management, will conduct a
seminar entitled “Advanced Techniques
in Billing and Coding for Family
Physicians.” The next scheduled event
for this day is an “Obstetrical Update,”
sponsored by the Charleston Area
Medical Center from 6:30 p.m. - 9 p.m.
In conjunction with this seminar, a
buffet dinner is being held at 5:30 p.m.

On Friday morning, the conference
will officially kickoff at 7 a.m. with
registration and a continental breakfast.
The first lecture, “Management of
Benign Prostatic Hyperplasia,” will then
be delivered at 8:30 a.m. by James B.
Regan, M.D., of Georgetown University
Medical Center in Washington, D.C.
Immediately following, W. James
Howard, M.D., of Washington Hospital
Center in Washington, D.C., will speak
on the subject of “Which Lipid Factors
Are Important from the Family
Physician’s Perspective.” The third
speaker that morning be David Pitts,
M.D., of the Chattanooga Cardiovascular
Risk Prevention Clinic, who will discuss
“Antihypertensive Agents: Their Effects
on Lipids, Glucose and Renal
Function.” This morning session will
then conclude with the lecture
“Diagnosis and Treatment of Migraine
Headaches” by Aubrey L. Knight, M.D.,
of the University of Virginia.

After lunch, Friday’s presentations
with reconvene with a lecture on
“Diagnosis and Treatment of Common
Fungal Infections” by Stephen Brozena,
M.D., of the James A. Haley Veterans
Hospital in Tampa, Fla. Holly Harris,
M.D., of South Bend Clinic in South
Bend, Ind., will then present a talk on
“Pediatric Dermatology.” The final
speaker for this afternoon session will
be Gary Stein, Pharm.D., of Michigan

State University, who will discuss
“Vaginal Candidiasis.” The day’s
activities will conclude with alumni and
all member parties.

Registration and a continental
breakfast will again begin at 7 a.m. on
Saturday. Three different meetings will
then take place at 7:15 a.m. - the
Sports Medicine Committee Breakfast
Meeting, the Resident Directors
Breakfast Meeting, and the Women in
Family Medicine Breakfast. Following
these events, a “Seminar on Women's
Health Issues” will be held at 8 a.m.
Topics to be discussed include
“Benefits and Risks of Estrogen-
Progestogen Replacement Therapy,” by
R. Donald Gambrell Jr., M.D.; “Heart
Disease in Women,” by Elizabeth B.
Connell, M.D.; “Abnormal Vaginal
Discharge: Obstetrical and
Gynecological Consequences,” by
Doris Brooker, M.D.; and “The Role of
Hormones in Etiology and Prevention
of Endometrial and Breast Cancer,” by
Dr. Gambrell.

After a break for several special
luncheons, Dr. Connell will again
speak to participants and this time her
topic will be “Contraception
Alternatives for the 90s." Another
speaker from the morning lectures, Dr.
Brooker, will then discuss “Prevention
of Physician Misconduct.” The final
speaker for the afternoon will be R.
Mark Hatfield, M.D., who will address
the subject of “The Diabetic Eye.”
Following these lectures, a cocktail
party, the annual banquet, and an after
dinner dessert/cordial party are planned.

Sunday’s activities will begin at 7 a.m.

with complimentary SMAC-20s by SVI.
Then, after registration and a
continental breakfast at 7:30 a.m., four
lectures are scheduled. The topics to
be covered include “Management of
COPD,” by Fernando Martinez, M.D.;
“New Antibiotics for the 21st Century,”
by Fred Bode, M.D.; “Pharmacology for
Left Ventricular Dysfunction,” by Craig
Barnette, M.D.; and “Management of
Hypertension in the Diabetic Patient,"
by George Arnoff, M.D.

This meeting has been reviewed and
is acceptable for 18.45 prescribed
hours and 3-50 elective hours by the
American Academy of Family Physicians.
AAFP prescribed credit is accepted by
the AMA as equivalent to the AMA PRA
Category 1. AO A credit toward
Category 2- A for 18.45 prescribed
hours and 3-50 elective hours is also
approved.

For more details, contact the WVAAFP
at 776-1178.

This year's WVSMA Annual
Meeting will again take place
during the same week as the West
Virginia State Fair, so if you wish to
stay at The Greenbrier, phone the
hotel at 1-800-624-6070 as soon as
possible for reservations.

Please turn to page 43 for more
details about the meeting or phone
the WVSMA at (304) 925-0342.

68 THE WEST VIRGINIA MEDICAL JOURNAL

Medical Savings Accounts

Michael Tanner, Ph.D., director of Health and Welfare Studies for the CATO
Institute, addresses the participants at the symposium on “Free Market Alternatives
to Health Care Reform,” which the WVSMA presented in Charleston on January 12.
Other speakers pictured included John Colbertson, president of Walker Aerospace;
Duane Parde, director of state legislation for the Council for Affordable Health
Insurance; and WVSMA President Dr. James Comerci.

Charleston to host first international health
conference on prevention in October

West Virginia has been chosen as
the host state for the First International
Conference on Prevention: The Key to
Health for Life , which will convene
from October 27-30.

This international conference is
being sponsored by the World Health
Organization; the Council of Geriatric
Cardiology; the Center for the Study
of Aging; the Robert C. Byrd Health
Sciences Center of WVU; the three
medical colleges of West Virginia; the
West Virginia Bureau of Public Health;
and U.S. Senator Jay Rockefeller.
Approximately 2,000 physicians, health
and insurance industry' professionals,
health care providers and businesses
from all over the world are expected
to attend.

The goal of the conference is to
share knowledge of innovative and
established prevention and health care
promotion programs in hopes of
replicating these programs in other
parts of the world. This international
conference is timely because of efforts
to reduce health care costs. Programs
of health prevention, health
promotion and delayed dependency
can save billions of dollars and
thousands of work hours.

West Virginia was chosen as the site
for this conference because of the

crusading efforts of Lawrence J.

Frankel. Frankel, who will celebrate his
90th birthday next year, introduced
West Virginians to a common sense
program called "Preventicaref more
than three decades ago. This program
is now recognized both nationally and
internationally.

At the conference, experts from the
United States, Australia, Germany,
England, France, Finland, Canada, and
many other countries will address high
profile prevention and health promotion
issues. Invited guest speakers include
First Lady Hillary Clinton; Surgeon
General of the United States Jocelyn
Elders; Secretary' of Health and Human
Services Donna Shalala; Public Health
Service Director Phillip Lee, M.D.; World
Health Organization Liaison Hana
Hermanova, M.D.; Senators Robert Byrd
and Jay Rockefeller; as well as
physicians, health care professionals,
and providers distinguished in the field
of prevention and health care
promotion.

Early registration for the conference is
suggested. For further information,
contact the First International
Conference Committee, 10 Hale Street,
Charleston, WV 25301, (304) 342-1200;
or the Charleston Chamber of
Commerce at (304) 345-0770.

Nominations being
taken for Country
Doctor Award

Staff Care, Inc., a temporary
physician staffing firm located in
Irving, Texas, is again accepting
nominations for the 1994-95 Country
Doctor of the Year.

Last year was the first year this
organization had awarded this honor
to a rural physician, and the
ceremony where the award was given
to Dr. John Harlan Hayes Jr. in Vivian,
La., gained national attention.

To obtain a nomination form, call
Staff Care, Inc. at 1-800-685-2272.

New study compares

tympanometry,

reflectometry

A recently published study in
Contemporary Pediatrics provides
some significant findings regarding
the diagnosis of otitis media with
effusion during the first 24 months of
life.

The study offers a comparison of
the two methods and concludes that
reflectometry is particularly more
accurate in the critical age group of 3
to 24 months.

A reprint of this study, as well as a
free loan copy of a video on sonar
and microprocessor technology, is
available by contacting ENT Medical
Devices, Inc. at 1-800-325-3015.

Wyeth- Ayerst offering
new patient materials

A new video entitled “ Hysterectomy
Kit, ” and a new booklet, " What a
Man Should Know About Menopause, ”
are now available from Wyeth-Ayerst
sales representatives.

In addition to these materials on
menopause, the company is offering
Seasons, a magazine for Premarin
patients; and the “Life After 45” series,
a comprehensive six-part program
about health issues affecting middle-
aged women.

FEBRUARY 1994, VOL. 90 69

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Marshall University School
of Medicine - Huntington

March 22

“7th Annual Research Day,” 8 a.m.

Raleigh County Medical Society -
Beckley

February 22

“Anti-Microbial Resistance,” Prosacl V.
Devabhaktuni, M.D., 6:30 p.m., Black
Knight Country Club

February 24

“Update on Fibromyalgia,” Stephen R.
Cirelli, M.D., 6:30 p.m.. Black Knight
Country Club

Robert C. Byrd Health Sciences
Center of WVU - Charleston

March 3

“Teleconference on the Pitfalls in the
Initial Evaluation of the Trauma
Patient,” noon - 1 p.m., HSC and
satellite locations

March 3-4

“Pediatric Advanced Life Support,”

8 a.m. - 5:30 p.m., CAMC Education
and Training Center

March 15

“Management of a Neck Mass”
(sponsored by The Eye and Ear Clinic
of Charleston and the Dept, of
Surgery), Mark K. Wax, M.D., 4th
Floor Faculty Lounge

March 17

“Teleconference on Abdominal
Distention and Vomiting in the
Newborn,” noon - 1 p.m., HSC and
satellite locations

April 19

“Mini and Maxi Flaps” (sponsored by
The Eye and Ear Clinic of Charleston
and the Dept, of Surgery), Ted
Jackson, M.D., 4th Floor Faculty
Lounge

Robert C. Byrd Health Sciences
Center of WVU - Morgantown

March 18-19

“AIDS in West Virginia” (sponsored
by the WVU Dept, of Medicine,
Section of Infectious Disease),
Charleston House Holiday Inn,
Charleston

March 25-26

“Spring Meeting of the West Virginia
Chapter of the American Academy of
Pediatrics” (sponsored by the WVAAP
and the WVU Dept, of Pediatrics),
Morgantown

West Virginia State Medical
Association - Charleston

March 12

Level I Loss Prevention Program -
Huntington

March 26

Marbury vs. Madison Loss Prevention
Program - Wheeling

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Gassaway □ Braxton County Memorial
Hospital, Feb. 23, 6:30 p.m., TBA,
Steven Jubelirer, M.D.

Logan □ Logan General Hospital,

Mar. 18, 11:45 a.m., “New Treatment
for Fibrillation/Flutter,” Ronald J.
McCowan, M.D.

Madison □ Boone Memorial Hospital,
March 8, 6:30 p.m., “New Treatment
for Fibrillation/Flutter,” Ronald J.
McCowan, M.D.

Montgomery □ Montgomery7 General
Hospital, March 2, 12:30 p.m., “New
Treatment for Fibrillation/Flutter,”
Ronald J. McCowan, M.D.

Oak Hill □ Plateau Medical Center,
March 22, 6:30 p.m., “New Treatment
for Fibrillation/Flutter,” Ronald J.
McCowan, M.D.

Parkersburg ★ Camden-Clark
Memorial Hospital, Feb. 23, 7 a.m.,
“Return to Work for the Injured
Worker: Principles and Caveats”

★ Camden-Clark Memorial Hospital,
Mar. 16, 7 a.m., "Management of
Obesity”

★ Camden-Clark Memorial Hospital,
Mar. 23, 7 a.m., “Some New or
Rediscovered Bacterial Pathogens”

Philippi ★ Broaddus Hospital, Mar. 3,

7 p.m., “AIDS”

Point Pleasant □ Pleasant Valley
Hospital, Feb. 24, noon,
“Appendicitis,” A. Margarita Torres,
M.D.

Spencer □ Roane General Hospital,
March 15, 12:15 p.m., “Disease of the
Larynx,” James Spencer, M.D.

70 THE WEST VIRGINIA MEDICAL JOURNAL

March

1- 2-Good Medicine is Good Business
(sponsored by the National Business
Coalition and the National Association of
Managed Care Physicians), Reston, Va.

2- 3-Challenge of the 90s: Ethical Issues in
Medicine (sponsored by Eastern Virginia
Medical School), Norfolk, Va.

4-5-The 37th Annual Postgraduate
Symposium in Ophthalmology: Diagnostic
Pathology (sponsored by Ohio State
University), Columbus

4- 9-American Academy of Allergy and
Immunology, Anaheim, Calif.

5- 10-21st Annual Critical Care Medicine
Course (sponsored by The University of
Oklahoma Health Sciences Center),
Oklahoma City, Okla.

5-12-Update in Clinical Medicine
(sponsored by The George Washington
University Medical Center), Vail, Colo.
10-13-Clinical Electrocardiography: Basic
Concepts and Interpretation - 14th Edition
(sponsored by Eastern Virginia Medical
School), McLean, Va.

12- Medical Management of the
Atherosclerosis Plague (sponsored by The
George Washington Medical Center), Atlanta

13- 17— American College of Cardiology,
Atlanta

18-Ultrasound in Abdominal Surgery
(sponsored by The George Washington
University Medical Center), Washington, D.C.
20-25-3rd Annual Cardiovascular Disease
Conference: The High-Risk Patient: An
Interspecialty Approach (sponsored by Ohio
State University), Snowmass- Aspen, Colo.

23- 26-Toward an Electronic Patient Record
‘94: Tenth International Symposium on the
Creation of Electronic Health Records and
Sixth Global Congress on Patient Cards
(sponsored by Medical Records Institute),
Washington, D C.

24- 25— West Virginia Urological Society’s
Annual Spring Meeting, Morgantown

April

5-9-20th Annual Meeting of the Society for
Biomaterials, Boston

9- Psychiatry Clinical Update: The Treatment
Resistant Patient: Thick Chart Syndrome
(sponsored by Ohio State University),
Columbus

10- 11— Planning Conference on Management
Requirements for a National Implant Data
System (sponsored by the Society for
Biomaterials), Hyannis, Mass.
16-Gastroenterology Update (sponsored by
Ohio State University), Columbus

For More Information . . .

Contact the Journal at (304) 925-0342.

Poetry Corner y

Make-Believe

The make-believe which children play
In innocence of early life.

Before the grown-up problems start,

Entices me to flee the strife
Which makes the days of later years
So full of worry, pain and tears;

Go back and play some make-believe;

Be like a care-free child once more;

Enjoy some days of hope-filled dreams;

Some days of youth and health restore;

Then look ahead to later years
While being free of rootless fears.

But in this life of grown-up truth
There is no time for make-believe;

For in this life's reality
We have to take what we receive,

And live our days of “golden years ”

The best we can among our peers.

E. Leon Linger, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward, M.D.,
Editor, West Virginia Medical Journal, P. O. Box 4106, Charleston, WV 25364.

" mat ONE OF THEMIS ir THAT WILL KILL fOU ? ... P0L<f SATURATE >
°FZ F0L<yvNSA TUFA TED 7 "

FEBRUARY 1994, VOL. 90 71

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

Agencies submit plans
for health reform

According to a new “white paper”
released by several public health
agencies in West Virginia, the role
and functions of public health must
be clearly defined and should serve
as the base for a reformed health care
delivery system.

The paper, “Public Health in the
Reformed State Health Care System,”
was developed by representatives from
the West Virginia Association of Local
Health Departments, the West Virginia
Bureau of Public Health and the West
Virginia Public Health Association,

Inc., in an effort to support positive
changes in the state's health care
system. It states that population-based
prevention services, protection of the
public’s health through enforcement of
policies, and promotion of individual
and community health behavior
changes are keys to long-term health
improvement in the state and nation.

This white paper represents a
consensus on the mission, roles,
structure, funding and transition efforts
for public health agencies at local,
regional and state levels in West
Virginia.

“We have the chance to make a real
difference to improve the access and
delivery of quality health care for the
people of West Virginia,” said Earl
Burgess, president of the West Virginia
Association of Local Health
Departments. “But to be successful, we
must be aggressive and innovative, and
we feel that many of the proposals in
this white paper do just that.”

Some of the proposals call for
changes in the focus of public health,
and Bureau of Public Health
Commissioner William T. Wallace, Jr.,
M.D., M.P.H., says many of those
changes are a revisit of the founda-
tion of public health values. “Health
care has too often become big
business, and many public health

agencies have joined in the competi-
tion,” said Wallace. “We need to look
at fulfilling the true missions of public
health as they are meant to be and
then at filling in the gaps in health
care delivery where they exist, rather
than duplicating available services.”

“We feel we’ve learned a lot, and
accomplished a lot, just by coming
together to talk about these issues,”
said Chris Gordon, president of the
West Virginia Public Health
Association. “We know we haven’t
always seen eye to eye on every
problem or solution, but we do agree
that public health must play a key
role in health care reform, and we
feel the proposals in this paper are a
good start to improving health care
for West Virginians.”

This document paper has been
presented to Governor Gaston
Caperton and to state lawmakers in
preparation for the upcoming
legislative session. If West Virginia is
a leader in health reform it’s more
likely to be awarded federal funding
for developing various parts of any
reform package.

State public health
official named
leadership scholar

Nancy ). Tolliver, R.N., M.S.I.R.,
deputy commissioner of the West
Virginia Bureau of Public Health, has
been selected to serve as a Scholar in
the third annual national Public
Health Leadership Institute. Ms.
Tolliver joins an elite group of the top
50 public health leaders in the
Institute’s year-long program.

The purpose of the Institute is to
strengthen America’s public health
system by enhancing the leadership
capacities of state public health
officials. Launched in July 1991, the
Institute is funded by the Centers for
Disease Control and Prevention
(CDC) and is conducted by the CDC
and the Western Consortium for
Public Health, which includes the
University of California at Berkeley,
the University of California at Los
Angeles and San Diego LTniversity.

AIDS programs
to target youth

The West Virginia Bureau of Public
Health AIDS Program is joining
national efforts to increase AIDS
education and prevention among
young people. As the U.S. Centers for
Disease Control and Prevention
(CDC) launches a new campaign
targeting people age 25 and younger,
the state AIDS Program is initiating
pilot youth programs in Kanawha and
Cabell counties.

The programs will go beyond
providing basic HIV/AIDS education.
Staff at agencies serving youth will be
assisted in promoting risk reduction
activities, including self-esteem
building, decision making and
negotiation skills. Cynthia Rinaldi, an
educator with the AIDS program, said
West Virginia’s young people are at
increased risk of HIV infection because
many don’t perceive themselves at
danger and continue risky behaviors.

“Look at the state’s rates for teen
pregnancy and sexually transmitted
diseases, and it’s obvious that many
teens are having sex without using
condoms,” Rinaldi commented. “It’s
very difficult to convince l6-year-olds,
who often believe they’re invincible,
that one incidence of unprotected sex
might put them at risk of dying 10
years later.”

AIDS Program statistics indicate that
the incidence of HIV among the
state's youth is increasing. Since 1984,
77 of 389 reported AIDS cases have
occurred in people in their twenties.
HIV often has an incubation period of
10 years or more, so many of these
people were probably infected as
teens. Since 1989, 17 of the 471 West
Virginians who have tested positive
for HIV were between the ages of 13
and 19. State Epidemiologist Loretta
Haddy estimates there are between
2,000 and 4,000 West Virginians who
are unaware they are HIV infected
because they have never been tested.

The West Virginia AIDS Program
offers many education and prevention
resources, including videotapes loaned
to the public free of charge. For more
details, phone the AIDS Program at
(304) 558-2950 or 1-800-642-8244.

72 THE WEST VIRGINIA MEDICAL JOURNAL

620 YARD PAR 5 • 620 YARD PAR 5 • 620 YARD PAR 5

West Virginia Chapter - American College of Surgeons

Annual Spring Meeting

May 5,6, & 7, 1994

The Greenbrier

White Sulphur Springs, West Virginia

Guest Speakers: Dr. David C. Sabiston, Jr., Professor and Chairman, Department of Surgery

Duke University Medical Center, May 5 at 11:45 a.m .-"Major Operations in
Surgical History" and May 6 at 11:15 a.m .-"Surgery of the Coronary Circulation, 1994"

Dr. Vaughan Starnes, Chairman, Department of Surgery and
Director of Cardiopulmonary Transplantation, University of Southern California,
May 5 at 10:45 a.m.-"The Ross Procedure for Aortic Valve Disease" and May 6 at
10:45 a.m.-" Current Indications for Lung Transplantation"

Jane Rothrock, R.N., Ph.D., President - Association of Operating Room
Nurses, May 6 at 10:15 a.m.-'T/ie RN as First Assistant"

Speakers from the Southwestern Pennsylvania Chapter, the West Virginia Chapter and resi-
dents from WV training programs will complete the program. Golf tournament and reception on
Friday. 10.5 hours CME. For room reservations, call The Greenbrier at 800-624-6070. For
information, call Sharon Bartholomew at 598-2802.

620 YARD PAR 5 • 620 YARD PAR 5 • 620 YARD PAR 5 • 620 YARD PAR 5 • 620 YARD PAR 5

“Nobody Gets Home In Two”

And no wonder . . . this is the monster, the terminator
of all holes, at 620 yards with an uphill dogleg left!

The famous hole #18 on the Lakeview Championship
Golf Course is a legend in itself, creating a reputation of
"Nobody gets home in two".

But that's not the only reason to journey to scenic Cheat
Lake in Morgantown, West Virginia.

• 36 holes of Championship Golf

• $2 million Fitness and Sports Center

• 1 87 guest rooms and suites

• 75 two-bedroom condominiums

• 24,000 square feet of meeting space

• 4 restaurants and lounges

• 3 swimming pools

• Indoor/outdoor tennis courts

• Racquetball and wallyball

• 2 Jacuzzis

• Horseback riding

• Boating

Play the 6,760 yard Lakeview course and the 6,447 yard
Mountainview course, then you'll know you've played
some of the most beautiful and challenging golf in the
East.

620 YARD PAR 5 • 620 YARD PAR 5 • 620 YARD PAR 5

Robert C. Byrd
Health Sciences Center

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Brazilian surgeon
introduces new
endoscopic equipment

WVU surgeons were recently shown
the newest instruments in endoscopic
surgery by Dr. Marco A. Correa, who is
on the staff of the Catholic University
Hospital's Department of Plastic Surgery
in Porto Alegre, Brazil.

Dr. Correa demonstrated the
tomoscope, a new instrument he
invented, which is very promising for
use in trauma patients because it
provides the surgeon a well-lit, hollow
space to perform operative procedures.

Dr. Correa worked with Dr. Julio
Hochberg, associate professor of
reconstructive plastic surgery, on
developing uses of these specially
designed scopes, which are inserted
through minimal incisions in the body.
The scopes, now being employed in
reconstructive procedures such as
breast reduction, allow surgeons to
magnify unclear images on a monitor.

According to Dr. Hochberg, these
scopes will simplify many surgical
procedures and diminish much of the
cutting and scarring. “Instead of
cutting,” he says, “we have begun
using a ‘puncture elevator’ which lifts
the breast tissue and allows us to
reduce it endoscopically.”

Ulcers can be treated
with antibiotics

Doctors at WVU
have recently
started to treat
their patients who
are suffering from
certain kinds of
peptic ulcers with
vigorous doses of
antibiotics.

This is a radical
departure from the
traditional methods of controlling diet
and lifestyle, and reducing stomach

acid. And, for many patients, it
appears to be much more effective at
eliminating recurrent ulcers.

In the early 1980s, Australian
researchers opened the door to new
ways of dealing with ulcers. They
demonstrated that over 90 percent of
people with duodenal ulcers, and 70
percent of those with gastric ulcers,
had the same strain of bacteria in their
stomachs.

“If we use the standard treatment,
which centers around medication and
a diet to reduce stomach acid, a large
number of people will have recurrence
of their ulcers because the bacteria are
still there," Dr. Ronald D. Gaskins,
gastroenterology section chief said. “If
we kill these bacteria with antibiotics,
most people show no recurrence of
ulcers.”

Dr. Gaskins points out that not
everyone with ulcers is a candidate for
antibiotic treatment. There is no
benefit in antibiotic treatment for
people whose ulcers are caused by
the use of aspirin or ibuprofen, or for
those who have ulcer symptoms
without having an ulcer. “For these
people, the standard treatment is still
the best: using antacids, drugs called
histamine receptor blockers, and diet
control,” he added.

Klingberg Center
awarded federal grant

WVU's W. G. Klingberg Center for
Child Development has received a
$800,000 grant from the U.S. Office of
Maternal and Child Health to help care
for children in West Virginia with
learning disabilities, mentally and
physically handicapping conditions,
and behavioral and developmental
problems.

The four-year grant is designed to
train families and professionals in
family-centered care. Trainees will
come from the State of West Virginia’s
Children with Special Health Care
Needs clinics ( formerly the Department
of Handicapped Children’s Services).

During the first two years of the
grant, training will take place at clinics
in the Morgantown area, and then it
will be taken statewide.

Faculty members
make presentations

Dr. Janie R. Vale, assistant professor
of occupational medicine, presented
two sessions at the Back Pain ’93
Conference in Boston. Her sessions
described the effect of the Americans
with Disabilities Act on treatment and
reimbursement for workers with
injured backs, and how to access
government-mandated health care.

Another faculty member, Dr. Mark
K. Wax, assistant professor of
otolaryngology, presented three
papers at the 87th Annual Scientific
Assembly of the Southern Medical
Association in New Orleans. His
co-authors included: Mike Hurst,

M.D., D.D.S., assistant professor of
otolaryngology; Gerald Nieusma,
D.D.S., associate professor of oral and
maxillofacial surgery; and Dr. Orlando
Ortiz, assistant professor of radiology.

In addition, Dr. Wax also presented
a poster he co-authored, and Dr.

Rohit Bawa, chief resident, presented
a paper entitled “Anaplastic Thyroid
Carcinoma” and two posters.

In Memoriam

Eric Humphries, Ph.D., 48, died
December 11. Dr. Humphries was a
professor in the Department of
Microbiology/Immunology and
scientific director of the Mary Babb
Randolph Cancer Center.

"It’s tragic to lose Eric at such a
young age,” says Fred Butcher,
Ph.D., director of the Cancer
Center. “We are going to miss his
positive and optimistic outlook. It
will be a tremendous challenge to
continue the standard of success
he established.”

Dr. Humphries is survived by his
wife, Caroline, and his four children.

Vale

74 THE WEST VIRGINIA MEDICAL JOURNAL

Our Name Says It All...

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Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University , Huntington.

HUD releases $4.5
million for Rural
Health Center

U.S. Senator Robert C. Byrd has
announced that the Department of
Housing and Urban Development has
released $4.5 million to establish the
Southern West Virginia Center for
Rural Health at Marshall.

The facility will serve as a base for
rural-oriented medical treatment,
teaching, research and support seivices,
according to Dean Dr. Charles H.
McKown Jr. Faculty will help provide
or coordinate services not otherwise
available in the counties of Cabell,
Wayne, Lincoln, Mingo, Mason,

Roane, Boone, Putnam, Jackson,
McDowell, Wyoming and Logan.

Providing approximately 27,500
gross square feet of space, the center
will house:

* Innovative and comprehensive
health programs;

* Special services and educational
programs for students and health
professionals;

* An improved library and learning
resources center; and

* The Marshall Rural Health
Research Institute.

“Basing these programs at a central
site will allow us to use our resources
more efficiently, as well as provide a
critical mass for focusing on rural
health needs,” Dr. McKown said.

Major projects of the Rural Health
Research Institute include determining
more effective methods to present
cancer prevention and early detection
information to rural populations,
developing ways to improve care for
elderly people in rural areas, and
measuring the effectiveness of programs
that tailor medical education to the
needs of rural areas. The institute also
is designed to provide support
services to assist rural providers who
want to conduct research projects.

Student health program
brings parents to school

In Lincoln County, health providers
and school officials are collaborating
on an intensive program designed to
increase both the number and the
impact of early periodic screenings,
and diagnostic and testing program
evaluations.

The school health program restores
a missing link in the student health
process: families. The program, which
is apparently the only one of its kind
in the nation, invites parents and
siblings to catch the school bus on
clinic day and go to school with
students.

“It takes parents to solve the
problems in health and education, so
instead of sending students home with
a generic consent form, we’re asking
the parents to come in with them,”
said Gerry D. Stover, executive
director of the Lincoln Primary Care
Center and a volunteer faculty
member at Marshall.

Parents can talk directly with
providers about the exam and their
child’s health. They also can
accompany their children through the
school day, do volunteer work, and
participate in parenting classes that
emphasize parental involvement and
building self-esteem. The program
reaches all Lincoln County elementary
schools and Guyan Valley High
School.

Dr. Robert B. Walker, chairman of
family and community health at
Marshall, said the program fills an
important gap.

“The beauty of this program is that
it gets parents together with the
provider and the child,” Dr. Walker
explained. “That has been a big hole
in the system — you can screen
children at school, but then how do
you assure follow-through with a
7-year-old? Our experimental concept
has been quite successful, with more
than 90 parents participating since the
program began last fall.

“This is a taie joint effort of the
Board of Education, the Lincoln
Primary Care Center and Marshall.
Participants in the screenings include
Lincoln County school nurse Pam

76 THE WEST VIRGINIA MEDICAL JOURNAL

marshalimJniversity

Dice (who also is seeking her master’s
degree through Marshall’s family
nurse practitioner program), LPCC
physician assistant Gary Culver and
medical students. Social workers from
the LPCC and Prestera Mental Health
Services also contribute to the
program.”

NIH investigator
featured speaker for
7th Research Day

Interested health professionals are
invited to attend the School of
Medicine’s Seventh Annual Research
Day on March 22 at the Holiday Inn
Gateway Convention Center in
Barboursville.

Students, residents and faculty will
offer research presentations and
clinical case presentations throughout
the day. Activities will begin at 8 a.m.
and will conclude with an awards
presentation and reception ending at
6 p.m. This year’s keynote speaker
will be Abner Louis Notkins, M.D.,
director of the intramural research
program and chief of the Laboratory
of Oral Medicine at the National
Institute of Dental Research.

For the Research Day Opening
Lecture, Dr. Notkins will speak on
“Polyreactive Antibody Molecules and
Natural Immunity.” This program will
begin at 7 p.m. on March 21 in the
Marshall Fine Arts Building, located
east of Hal Greer Boulevard on Fifth
Avenue.

Dr. Notkins will also lecture on
“The Bethesda Experiment” for the
Research Day luncheon which will
take place on March 22 at noon at the
Gallery. His research interests lie in
the etiology, pathogenesis and
molecular biology of viral,
autoimmune and endocrine diseases
with emphasis on diabetes mellitus.

He has had approximately 300
scientific papers published, and has
edited four books.

To obtain more information or
register, call 696-7019.

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WESPAC Members

We would like to thank the
following physicians and alliance
members for their 1994 contributions to

WESPAC:

Physicians

A Dollar A Day Club

*designates more than $365 in
contributions

Boone

Ron Stollings
Cabell

Rodger Blake
William Lavery
Craig M. Morgan
Jose Ricard
Deleno H Webb III

Central

J.E. Echols
William Given

Eastern Panhandle

Edward Arnett
Hans-Udo Juttner
Joseph McCabe
Edward Pinneyjr.

Danine Rydland

Greenbrier

"Stephan Thilen
Hancock

Antonio S. Licata
Sarjit Singh

Harrison

*James Bryant
Thomas Chang
Carl W. Liebig
Florencia Lopez
*Doug McKinney
"Carlos A. Naranjo
"Louis Ortenzio Jr.

Kanawha

William Deardorff
Michael Fidler
Paul Francke
Donald Farmer
William Harris
Terry Perrine
Samuel Strickland
Eward H. Tiley 111

Marion

Mohammad Roidad
Mason
Ismael Jamora
Monongalia

Paul Clausell
Joseph G. Feghali
Richard S. Kerr

Roger E. King
Stephen R. Powell
Paul Malone
Matthew Midcap

Ohio

Hugo Andreini
David Bowman
James Comerci
Alfred D. Ghaphery
Steven Miller
John Tellers
Bennett E. Werner

Parkersburg

"Charles Loar

Raleigh

Anne D. Hooper
William D. Hooper
Owen C. Meadows Jr.
"Robert P. Pulliam
Angel L. Rosas-Acededo
William Scaring
Norman Siegel
Norman Taylor
Nancy R. Webb
Michael Webb

Regular Members

Cabell

William Kopp

Central

Joseph Reed

Fayette

Enrique Aguilar

Greenbrier

Steven Hefter
Thomas Mann

Harrison

Louis Ortenzio Jr.

Kanawha

Moutassem B. Ayoubi
John Byrd
William Carter
Stephen Cassis
Vera Hoylman
Shozo Kurusu
Stephen Milroy
Muhib S. Tarakji
Isidro Uy
Nathan Vaughan

Marshall

Thomas Dickey Jr.
Howard Neiberg

Mason

Benjamin Sol
Monongalia

Roger Abrahams
William Cutlip II

Anne C. Cutlip
Indira Majumder
Vadrevu Raju

Ohio

Terry A. Athari
Regina Barberia
Frederick Payne
Richard Terry
Carlos A. Vasquez

Parkersburg

E. Samuel Guy
Thomas Tamay

Raleigh

Lewis Gravely
Joseph Maiolo
Narendrakumar M. Patel

Tug Valley

Diane E. Shafer

Sustainer Members

Cabell

S. Kenneth Wolfe
Stephen J. Feaster

Eastern Panhandle

James Carrier
Daniel Hendricks
Edward Quarantillo Jr.
Danine Rydland

Greenbrier

Kyle Fort

Thomas Kowalkowski
David Meriwether

Hancock

Charles Capito
Harrison

Chinmay Datta
Frank Gyimesi
Mehmet Kalaycioglu

Kanawha

Gina Busch
Brad Cohen
Edmundo Figueroa
Chung Kim

Elizabeth Ann Roseberry
Ujjal S. Sandhu
Ralph S. Smith Jr.

L. Blair Thrush Jr.

Logan

Joby Joseph
Marion

John Leon
Stanard Swihart

Mason

Young Choi
Ismael Jamora
John A. Wade Jr.

78 THE WEST VIRGINIA MEDICAL JOURNAL

WESPAC Cont.

Mercer

Albert J. Paine
Monongalia

Eugene S. Laplante
David Myerberg

Ohio

Terry Elliott
Ellen L. Kitts
Robert Joseph
Steven C. Miller
Martin Reiter
Byron Van Pelt

Parkersburg

Jorge Prieto
Preston

Max Hamed
Raleigh

Eileen Catterson
Sung Chang
Charles Daniel
Carlos Lucero
Richard Richmond

Tygarts Valley

Joseph Tavolacci

Extra Milers

Eastern Panhandle

Vigilio Tan
Kanawha

Constantino Amores
Samuel Davis
Cecilio Delgra
Hans Lee
Mickey J. Neal
Richard Sibley

Marshall

Kenneth Allen
Raleigh

Mario Ramas
Donald Rasmussen
Rajnikant Shah

Alliance

Regular Members

Eastern Panhandle

Ginny Reisenweber

Sustainers

Eastern Panhandle

Sara Townsend

Raleigh

Carole Scaring

New Members Society News

We would like to welcome the
following new members to the

WVSMA:

George B. Wilson, M.D.

301 Medical Arts Building
Charleston, WV 25301

M. Sandra Copley, M.D.

Fort Gay Primary Care
#\ High Street
Fort Gay, WV

Robert Palguta, M.D.

Davis Clinic
Kingwood, WV 26537

Judy Burroughs, M.D.

1710 Harper Road
Beckley, WV 25801

Jerry Frame, M.D.

St. Mary’s Hospital
2900 1st Avenue
Huntington, WV 25702

Joseph L. Skeens, M.D.

P.O. Box 11137
Charleston, WV 25339

Mark Younis, M.D.

P.O. Box 11137
Charleston, WV 25339

David Knitter, M.D.

1265 Pineview Drive
Morgantown, WV 26505

James Goetz, M.D.

1115 20th Street
Huntington, WV 25703

Sandra Marshall, M.D.

1115 20th Street
Huntington, WV 25703

Erez Ofir, M.D.

1000 Mourning Dove Drive
Blacksburg, VA 24060

Zdenek Otruba, M.D.

12 Fairland Drive
Bluefield, VA 24605

Kenneth Parker, M.D.

27 Pigeon Roost
Princeton, WV 24740

McDowell

At the Society’s December meeting,
members continued their discussion
about whether they should disband as
a component society.

Dr. Herland, president of the
McDowell County Medical Society,
mentioned that in November, a
motion to disband had failed to carry,
with three members voting in favor
and five members abstaining.

Dr. Kuppusarni then made a motion
to disband the society and it was
seconded by Dr. Vega. Only two
members voted for the motion, so it
failed to pass for lack of a majority.
The question of officers for 1994 was
then raised by Dr. Herland and the
members decided to maintain their
present leaders.

At their January meeting, the
members discussed Dr. Herland’s
proposal to form a speakers bureau.
Members were also given a treasurer’s
report by Dr. Michaelis.

PHYSICIAN

through

It’s the professional edge
in patient satisfaction and
medicine compliance.

Prescribing the right medicine
isn’t enough. It’s important to
follow through and explain how
and when to take it, precautions
and side effects.

The National Council on Patient
Information and Education
(NCPIE) has free materials to
help you talk about prescriptions.

Write for free information
on patient medicine
counseling.

“! Ur

NCPIE

666 Eleventh Street, NW
Suite 810

Washington, DC 20001

FEBRUARY 1994, VOL. 90 79

Obituaries

William W. Guthrie, M.D.

Dr. William W. Guthrie, 73, of
Montreat, N.C., formerly of Huntington,
died November 24 at home.

Dr. Guthrie was retired from
Huntington Physicians and was a
former administrator at Guthrie
Memorial Hospital. He was a graduate
of the University of Pennsylvania and
the University of Maryland.

An Army veteran of World War II,
Dr. Guthrie was a member of Black
Mountain Presbyterian Church and a
former member and elder of First
Presbyterian Church in Huntington. In
addition to being a member of the
WVSMA, Dr. Guthrie was a member
of the AMA and the Cabell County
Medical Society.

Surviving: wife, Mary Lou Guthrie;
sons, William of Atlanta, Dr. Robert of
Columbus, Ohio, and Dr. David of
Chambersburg, Pa.; mother, Carolyn
Guthrie of Minneapolis; sister,

Margaret Smith of Minneapolis; and
eight grandchildren.

Memorials may be made to the
Black Mountain Presbyterian Church
Building Fund or Swannanoe Valley
(N.C.) Habitat.

Kenneth M. Harman, M.D.

Dr. Kenneth McKee Harman, 45, of
Charleston died November 26 at
Charleston Care Center after a long
illness.

Dr. Harman was a partner of
Charleston Gastroenterology Associates
and a clinical associate professor of
medicine at the Robert C. Byrd Health
Sciences Center of WVU, Charleston
Division. He attended Elizabeth
Memorial Church in South Hills.

A 15-year resident of Charleston
and a Navy medical veteran, Dr.
Harman was a graduate of the West
Virginia University School of
Medicine. He interned at the Naval
Medical Center in San Diego,
completed a residency at CAMC, and
then served a fellowship at Duke
University Medical Center.

Dr. Harman had been a member of
the WVSMA since 1983 and was a
member of the Kanawha County
Medical Society.

Surviving: wife, Patricia Griffith
Harman; son, Robert of Charleston;

daughter, Kara Elizabeth Harman of
Charleston; parents, Quinten V. and
Mary Virginia Sinnett Harman of
Mozer; and sisters, Barbara Rohrbaugh
of Maysville and Faye Hedrick of
Petersburg.

Memorial donations may be made
to the CAMC Foundation, 3100
MacCorkle Avenue, Charleston, W.Va.
25304, c/o Dr. Bert Bradford.

Frederick V. Lilly, M.D.

Dr. Frederick Vivan Lilly, 78, of
Beckley died February 2 in a
Princeton hospital following a short
illness.

Dr. Lilly was born in Glen Morgan
and was a graduate of the West
Virginia LTniversity School of
Medicine. He was a World War II
veteran, having served his internship
at the U.S. Navy Hospital in Bethesda,
Md., as a medical officer.

Dr. Lilly was in general practice in
Rainelle and Beckley, and had been
an ear, nose and throat specialist in
Beckley since 1955. In addition to
being a member of the WVSMA, Dr.
Lilly was a member of the AMA and
the American Board of Otolaryngology.
He was certified by the American
Board of Otolaryngology.

A staff member at Beckley
Appalachian Regional Hospital,
Beckley Hospital and Raleigh General
Hospital, Dr. Lilly was a past president
of the Raleigh County Medical Society
and of the medical staff at Raleigh
General Hospital. He was a past
member of the board of directors at
Black Knight Country Club, and was a
past president and chairman of the
board at First National Bank in
Beckley.

Survivors include his wife, Lena Lee
Pollastrini Lilly; three sons, Fred Lilly
II of McLean, Va., Eric Lilly of
Greensboro, N.C., and Thomas Lilly of
Ft. Lauderdale, Fla.; a daughter,

Sandra Lee Fitzmaurice of Louisville,
Ky.; two brothers, Ira Lilly of Jumping
Branch and Keith Lilly of Dale City,
Va.; a sister, Shirley Lester of Jumping
Branch; and five grandchildren,
Frederick V. Lilly III, Tricia Lilly,
Preston B. Lilly, E. Van Lilly and Scott
Fitzmaurice.

Memorials may be made to the
WVU School of Medicine in
Morgantown.

Jack Pushkin, M.D.

Dr. Jack Pushkin, former chief of
orthopedics at Charleston Area
Medical Center, died December 15 at
home of cancer. He was 6l.

Born in Charleston, Dr. Pushkin
was a 1963 graduate of the West
Virginia University School of
Medicine. He interned at the
University of Minnesota Hospital and
then completed a residency in
orthopedic surgery at the WVU
Medical Center from 1964-68.

During the 1973 Arab-Israeli war,

Dr. Pushkin flew to Israel, where he
volunteered as a battlefield surgeon,
working sometimes two or three days
on end trying to hold together bodies
and preserve lives.

Dr. Pushkin discovered he had
cancer of the liver in 1991. He
underwent 16 hours of surgery in
Pittsburgh to replace his liver, remove
his spleen, pancreas, transverse colon
and three-fourths of his stomach. After
staying in the hospital three months,
he came home and gradually regained
his strength.

A member of the WVSMA since
1969, Dr. Pushkin was also a member
of the American Academy of
Orthopedics, Eastern Orthopedics
Association and Orthopedic Surgical
Trauma Association. He was a veteran
of the Korean War and a member of
B’Nai Jacob Synagogue and B'Nai
Brith.

Surviving: wife, Pamela Maynor
Pushkin; sons, David of New York
City, Michael of Morgantown and
Joshua at home; daughters, Lesli
Sterling of Los Angeles and Leah
Pushkin at home; brother, Dr. Martin
Pushkin of Morgantown.

Memorial contributions can be
made to the Juda B. Pushkin
Memorial Foundation, care of Cookie
Glasser, Suite 311, 815 Quarrier St.,
Charleston, W.Va. 25301 or B’Nai
Synagogue, Charleston.

80 THE WEST VIRGINIA MEDICAL JOURNAL

West: Virginia Medical

IOURNAL

March 1994

West Virginia State Medical Association

Volume 90 No. 3

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

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EDITOR

Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Published monthly by the West Virginia
: State Medical Association under the direction
of the Publication Committee. Original
articles are accepted on the condition that
they are contributed solely to the West
Virginia Medical Journal.

Postmaster send form 3579 to the West
Virginia Medical Journal, 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL IQURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $36 a year in the U.S.;
$60 in foreign countries; $3 per single copy.
Address communications to the West
Virginia Medical Journal, P. O. Box 4106,
Charleston, WV 25364.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Roaa,
Ann Arbor, MI 48106.

USPS 676 740
ISSN 0043 - 3284

West Virginia Medical

OURNAL

Contents

Special Section

Highlights of the West Virginia State Medical Association’s

1994 Mid-Winter Seminars and Scientific Conferences 90

Feature Article

Practice satisfaction among young West Virginia

family physicians 96

Scientific Newsfront

Intraoperative use of rtPA for subarachnoid hemorrhage 98

Spinal epidural metastases: A common problem for the

primary care physician 101

Geophagia in a chronic hemodialysis patient 106

President’s Page

To legislate or not to legislate? 110

Editorial

Saving big dollars Ill

In My Opinion

The new physicians -- kill or cure? 112

Special Correspondence 113

Special Departments

General News 114

Physician’s Recognition Awards 116

Continuing Medical Education 117

Medical Meetings/Poetry Corner 1 18

Bureau of Public Health News 120

Robert C. Byrd Health Sciences Center of WVU News 122

Marshall University School of Medicine News 124

WESPAC Members/Obituaries 126

1994 Advertising Rates 128

Classified 129

March Advertisers 130

Front Cover

The view from Silver Creek Ski Resort in Pocahontas

County. Photo courtesy of David Fattaleh, West Virginia

Division of Tourism and Parks.

MARCH 1994, VOL. 90 89

SPECIAL SECTION

Mid-Winter Clinical Conference

Highlights of the West Virginia State Medical Association's
1994 Mid-Winter Seminars and Scientific Conferences

January 20-23, 1994

Lakeview Resort and Conference Center
Morgantown, West Virginia

We thank the participants in the WVSMA's 1994 Mid-Winter Seminars and
Scientific Conferences for their support of this program. Your commitment
strengthens the Association and is vital to its continuing success.

Robert Hall, Ph.D., professor of philosophy and
sociology at West Virginia State College, listens
attentively to a participant’s comments during
his presentation on “Physician-Assisted
Suicide.”

Dr. Norman Taylor uses his pencil for extra
emphasis when asking a question at the
Physician/Public Session.

Dr. Alvin Moss of WVU gestures with his hand as he begins his lecture, “Health Care
Decision Making in West Virginia: Effect of the New Statutes,” for the First Scientific
Session on “Moving Points in Medicine.” This session was jointly sponsored by the
West Virginia Chapter of the American College of Physicians and the WVSMA.

Sometimes you just can’t take health care reform so seriously . . . Panelists Dr. James
Borland Jr., treasurer of the American College of Physicians; Dr. Skip Turner, a past
president of the WVSMA; and WVSMA President Dr. James Comerci enjoy the
humorous remarks of a colleague during the Physician/Public Session.

The proud recipients of this
year’s Laureate Awards from
the ACP were Dr. Maurice
Mufson of Marshall University
and Dr. Rashida Khakoo of
West Virginia University.

MARCH 1994, VOL. 90 91

Mid-Winter Conference Highlights

Guests such as Nancie Divvens, WVSMA
associate executive director, displayed their
musical talents by singing along with the laser
karaoke machine operated by Dr. Rano Bofill in
conjunction with the Dr. Jun Neri show.
Nancie’s version of “Crazy” was a real crowd
pleaser.

Dr. Daniel Foster steps out in style during his
rendition of “Hey, Good Lookin’.”

Veteran performer Dr. Jun Neri of Princeton presented a fabulous evening of
entertainment at the conference.

WVSMA Executive Director George Rider and WVSMA President Dr. James Comerci
teamed up to sing “On the Road Again.”

Their mothers have nothing
to worry about . . . Dr.
Norman Taylor, WVSMA
Council Chairman Dr. Robert
Pulliam and WVSMA General
Counsel Michele Grinberg
sang “Mommas Don’t Let
Your Babies Grow Up to Be
Cowboys.”

92 THE WEST VIRGINIA MEDICAL JOURNAL

David Bailey of the MU Office of CME, and his
wife, Pam, chose the romantic Stevie Wonder
tune, “I Just Called to Say I Love You," for their
laser karaoke number.

Sporting his camera, Dr. Edward Pinney
enjoyed performing for the audience.

While her husband. Dr. Rano Bo fill, operated the laser karaoke machine, Judy Bofill
sang a duet with Dick Ledford of I. C. Systems, Inc.

The more the merrier . . . Dr. Lewis Cook (left), Gary and Tamara Lively, and
Michele Sull and her finance Michael Myers made their musical debut with WVSMA
President Dr. James Comerci.

Belting it out like Sinatra
- Dr. Kurt Palazzo sele<
favorites of "Old Blue !■>

V ; d.; | * whenevt-r he took a tur

; ,ht‘ microphone durist,'-

r *1%, ' ■■ : evening.

MARCH 1994, VOL. 90 93

Mid-Winter Conference Highlights

Dr. Alan Ducatman comments about one of his
slides during his lecture for the Symposium
on Environmental Medicine and Patient
Communication, which was co-sponsored by
the WVSMA and the National Institute for
Chemical Studies in Charleston.

AMA Trustee Dr. Randolph Smoak Jr. (second from left) responds to a participant’s
question about the Clinton health care plan during the Lunch and Learn at the
conference. The other panelists for this event included Dr. Robert D’Alessandri, vice
president for health sciences and dean of the WVU School of Medicine; WVSMA
President Dr. James Comerci; and WVSMA Council Chairman Dr. Robert Pulliam.

Representatives from New Century Imaging, Inc. demonstrate a
computer system for Dr. Richard Hayes of Charleston.

Dr. Derrick Latos, a past-president of the
WVSMA, directs a question to a speaker
during the First Scientific Session.

Mark Wright, president of the WVSMA Medical Student Section from 1993-94,
addressed the students about a variety of issues at their annual meeting.

Two of the faithful exhibitors who braved the snowy weather
to attend the conference were Axin Hammack and Teresa Ansell
of Saint Francis Hospital in Charleston.

94 THE WEST VIRGINIA MEDICAL JOURNAL

The West Virginia State Medical Association’ s

August 17-20, 1994

The Greenbrier

White Sulphur Springs, West Virginia

Please be sure to make hotel reservations in advance by calling 1-800-624-6070. The Greenbrier
will fill up quickly because the State Fair will be going on during the same week.

Space is being held at other area hotels/motels, contact the WVSMA at 304-925-0342 for more
details. For your convenience, you may call the WVSMA office and register for the conference using
your Visa or Master Card.

1994 Annual Meeting

Name

Address

City State Zip Code

Specialty

Payment by: Check Visa MasterCard

Card Number

Expiration Date

Conference Cost:

WVSMA member

$125

non-member

$175

Additional:

Thursday, Aug. 18
Learn and Learn

member/non-member

$40

(CME Credit)

spouse/student

$25

Friday, Aug. 19
Lunch and Learn
(CME Credit)

member/non-member

$40

spouse/student

$25

TOTAL:

Signature

Lf paying by check, please send registration form and check to:
West Virginia State Medical Association
P.O. Box 4106, Charleston, WV 25364

Feature Article

Practice satisfaction among young West Virginia
family physicians

JAMES D. HELSLEY, M.D.

Vice President of West Virginia State Medical
Association; and Assistant Professor of Family
Medicine, Robert C. Byrd Health Sciences
Center of West Virginia University,
Morgantown, W. Va.

MARIAN L. S WINKER M.D., M.P.H.

Associate Professor, Department of Family
Medicine, Robert C. Byrd Health Sciences
Center of West Virginia University,
Morgantown, W.Va.

Abstract

Young family physicians, those in
their first five years of practice,
were surveyed to determine their
satisfaction regarding various
aspects of their practices. A total of
67% of the physicians surveyed
responded and the results indicated
that most family doctors located in
communities where there was a
perceived need for their specialty.
Tlje survey also showed that two of
the most important factors
necessary to attract and retain
family doctors in rural practice are
enhanced third-party reimbursement
and the availability of other family
physicians to share call This study
underscores the necessity to know
and understand the sentiments of
West Virginia family physicians in
order to attract more newly-trained
doctors into rural practice.

Introduction

Specialty choice for most physicians
is a difficult decision, and family
physicians, in particular, have
increasing challenges in selecting this
field of medicine. Since retaining good
family physicians in rural areas of
West Virginia is so important, this
survey was conducted to understand
the motivating forces behind career
choices, practice type and location, as
well as evaluate the level of satisfaction
with practices in this specialty.

Methods

In the spring of 1993, surveys were
mailed to 125 family physicians who
had entered practice in the past five
years. This four-page questionnaire
asked each respondent about the size
of his/her practice, community
population, practice scope, age, sex,
marital status, children, night call
frequency, and board status.

Satisfaction ratings from 0-3 were
requested for location, practice scope,
call frequency, professional
satisfaction, vacation coverage, CME
availabilities, cultural activities, family
ties and recreational opportunities. In
addition, respondents were asked to
hypothetically choose a practice
location and rate the desirability and
importance of various characteristics.
Comments were solicited at the end of
the questionnaire and ample room
was left for comment.

Mailing lists were obtained from
AAFP data and they were reviewed to
avoid duplication. Anonymity was
maintained and results were transferred
to a computer spread sheet.

Results

Of the 125 surveys mailed, 84 were
returned for a 67% response rate. Out
of the total who responded, 72 (86%)
were board certified family physicians;
38% were residency trained; 83% were
married; and 69% had children. The
average age for men responding was
35.4 years and for women was 36.8
years.

A total of 38% of the physicians
responding practiced in communities
with populations of less than 5,000.
One third were solo practitioners, and
less than half were in groups of three
or more. The clear majority of these
physicians were in private practice,
i.e. fee for service, with only 5%
involved in managed care practice
arrangements.

About 85% of all physicians
reported their practices as office
based, but one out of four did not
involve a hospital practice. Only 25%
of the physicians surveyed practiced

obstetrics, 59% practiced in ICU or
CCU settings, and 27% practiced all or
part time in emergency departments.
Almost one fourth had privileges at
more than one hospital.

Only 16% of these family physicians
were involved in teaching more than
20% of the time. In addition, one third
(33-5%) experienced nightly call, and
only 15% have no night call.

For the most part, the responding
physicians rated medium to high
satisfaction with the characteristics of
their practice (Scale 0 - 3). Considerable
satisfaction with practice location
(2.45) and scope (2.65) were reported.
Less satisfying aspects of their practices
included characteristics of lifestyle
(2.15), availability of non-professional
pursuits (2.4), overall enjoyment of life
(2.5), and availability of professional
coverage (2.25). The lowest satisfaction
rating (2.0) was reported for practice
income.

When these physicians were asked
why they located in their particular
setting, a majority stated that
community need was the most
important factor (2.1). The least
attractive feature that led to establishing
their practice in a particular location
was the economic climate of the state
(.85), followed closely by availability
(or lack) of cultural amenities (.95).
Significant positive factors also
included family ties (1.35), contact
with friends (1.6), as well as nearby
recreational opportunities (1.45), and
a location-incentive package (1.4).

The needs of a spouse were
marginally important (1.15).

Interestingly, most respondents
indicated the likelihood to choose a
practice in the same area if given the
opportunity to do so, and they would
favor an area more urban than rural. A
significant number of physicians
indicated a desire to leave the state
and a few expressed a desire for
either a more limited or broad-based
practice. A few doctors stated they
would opt for a larger hospital with
more sub-specialists. In addition, more
family physicians ranked back-up as a
desired option (1.2), and relocation to

96 THE WEST VIRGINIA MEDICAL JOURNAL

a more prosperous area was slightly
less important (1.1).

To encourage young family
physicians to locate in a rural practice,
the respondents suggested a number
of factors (Figure 1). The highest rated
factor was the desire for more family
physicians with which to share call
coverage (2.7), followed closely by
higher reimbursement (2.55). Loan
repayment and salary guarantees were
also major factors (2.5 each), as were
school opportunities for children (2.45).

Lesser, but still significant factors for
encouraging young family physicians
to locate in a rural practice, were
medical school and residency training
rural experience (2.35), the need to
improve the malpractice climate (2.25),
tertiary medical center contact (2.05),
recreational opportunities (2.05),
cultural amenities (1.85), and CME
opportunities (1.75). Of special interest
is the fact that the rural background of
a physician (2.05) or that of a spouse
(1.95) were perceived as factors with
only modest significance.

Discussion

Campos-Outcalt and Senf (1)
reported in their study that medical
students choose family medicine as a
career based on three factors: the
greater number of weeks of required
family medicine rotation, the
proportion of faculty in family medicine,
and ownership of the school. Their
study also indicated a need to search
for other factors of influence.

The results of our investigation
reveal that young West Virginia family
physicians are basically satisfied with
the location and content of their
practice. Although not uniformly so,
most physicians surveyed would choose
the same site over again. The family
physicians questioned seemed pleased
with their rural locations and lifestyles.

The decision to locate in West
Virginia seemed to be related to
community need more than any other
factor. This was reported as more
important than family “roots” or
personal friends located in a particular
area and is contrary to popular belief.

West Virginia’s economic climate is
a disincentive for family doctors to
locate in this state. In our study, it was
the lowest ranked factor that led to
the choice of a West Virginia practice
and only eight respondents indicated
economic climate as an attractive
feature.

If given a choice to select criteria
for enticing a young physician to
locate in a rural practice, the surveyed
physicians clearly made two points:

1) The most important factor that
would attract more family
doctors to a rural practice
location is the presence of other
family doctors in the area; and

2) Almost as important is the need
for greater reimbursement for
family physician services.

The survey revealed that family
doctors are in West Virginia because
of community need more than
anything else. “Threats to survival” for
these physicians include low third-
party reimbursement and the lack of
colleagues for cross coverage. One
third of the physicians in the survey
are on-call every night and it requires
an exceptional individual to continue
this lifestyle for very long.

During the 1980s, U.S. medical
schools experienced a decrease in
class sizes (2). Along with this trend
came a declining percentage of
graduating doctors choosing a career
in family medicine, and shortages in
family physicians now exist in all
parts of the country (3).

Many experts agree there is a need
to train and retain competent family
physicians. There has also been a
reduction in the number of medical
school graduates choosing fields other
than family medicine (4). As pointed
out in the results of this survey, low
third-party7 reimbursement for family
physicians is a considerable negative
factor in attempting to attract and
retain these doctors in West Virginia.
Repayment of medical school
indebtedness as an influence of career
choice has not been born out by the
statistics in national surveys (5);
however, reimbursement for services
once in practice seems to be a strong
issue.

Conclusions

This survey indicates how young
family physicians in West Virginia
would like to make practice in this
state more attractive. The two most
important factors are third-party
reimbursement levels and cooperation
with other family physicians in the
area. Cultural activities, recreational
activities and CME availability were
not reported as strong incentives.

The results of this survey
demonstrate the need to investigate
the requirements of young family
physicians in West Virginia in more
detail. Other rural states are
addressing this subject (6,7). West
Virginia family physicians need
support and encouragement to
facilitate the recruitment of more
young family physicians.

References

1. Campos-Outcalt D, Senf J. Medical school
financial support, faculty composition, and
selection of family practice by medical
students. Family Medicine 1992;Nov-Dec
24(8): 596-601.

2. Fahey, Sachs, Bauer. Declining class size and
the decline in graduates choosing family
medicine. Academic Medicine 1992;
67(10):680-4.

3. Scherger, et al. Responses to questions about
family practice as a career. American Family
Physicians 1992;46(l):115-25.

4. Kassebaum D, Szenas P. Specialty
preferences of graduating medical students:
1992 update. Academic Medicine 1992;
67(ll):800-5.

5. Kassebaum D, Szenas P. Relationship
between indebtedness and the specialty
choices of graduating medical students.
Academic Medicine, 67(10):700-7.

6. Goldsmith G. Addressing the states' need for
primary care. J of the Arkansas Medical
Society 1992;89(4):173-5.

7. Sherwood, Porcher, Hess. Utah model for
promoting rural primary care practices. Family
and Community Health 1993;l6(l)l67-72.

MARCH 1994, VOL. 90 97

cientific Newsfront

Intraoperative use of rtPA for subarachnoid
hemorrhage

JOHN H. SCHMIDT III, M.D., F.A.C.S.

JANE T. CHRISTENSON, PA-C

Department of Neurosciences, Charleston
Area Medical Center, Charleston, W.Va.

Abstract

Intraoperative thrombolysis with
recombinant tissue plasminogen
activator ( rtPA ) was performed in
15 patients with aneurysmal
subarachnoid hemorrhage. All
patients had significant basal
cistern blood accumulation seen on
CT scans preoperatively. The
patients underwent surgery within
four days of subarachnoid
hemorrhage with aneurysm clipping
in all patients. Postoperatively,
transcranial doppler examinations
demonstrated reduction in the
development of vasospasm to a
greater degree in patients treated
with rtPA than a similiar group of
patients managed without the rtPA
treatment. Eighty percent of patients
receiving intracistemal rtPA had
fair to good results compared with
78% of a similiar group of patients
who underu’ent surgery shortly
after subarachnoid hemorrhage
and were not given rtPA.
Intracistemal rtPA remains an
adjunctive treatment of questionable
benefit in the management of
patients with aneurysmal
subarachnoid hemorrhage.

Introduction

Intracranial aneurysms occur in
approximately 5% of the population at
large (1) and each year approximately
2%-3% of patients harboring
“congenital” berry aneurysms suffer
the effects of subarachnoid
hemorrhage (2). Without surgical
treatment, approximately 25% of
patients will have a second
subarachnoid hemorrhage within two
weeks, and the mortality of ruptured
intracranial aneurysms approaches
43% at one week without surgery (3).

Craniotomy with aneurysm clipping
is usually the standard treatment for a
ruptured aneurysm. Common
complications that can arise include
cardiac arrhythmias, hypotension,
serum inappropriate antidiuretic
honnone secretion and pneumonia (4).
The frequently observed complication
of delayed ischemic neurologic deficit
secondary to cerebrovasospasm
occurs whether or not surgery is
carried out to prevent aneurysm re-
rupture (5). In addition, vasospasm
will appear in approximately 30%-40%
of patients. These individuals will
have significant blood in the basilar
subarachnoid cisterns (6) (Figure 1),
and their extent of vasospasm is
measurable by angiogram (Figure 2).

Recently, transcranial doppler (TCD)
has been used to demonstrate the
degree of arterial velocity increase
which is proportional to the severity
of vasospasm (7). Vasospasm and its
associated delayed ischemic
neurologic deficit is likely to be the
leading cause of death from
subarachnoid hemorrhage (8). Several
ancillary therapies for vasospasm have

recently been developed including the
use of Nimodipine as a prophylaxis.
Treatment with hypertensive,
hemodilutional hypervolemia has
been employed to improve cerebral
blood flow during the period of
symptomatic vasospasm, which
usually lasts from one to two weeks
(9). Intraoperative recombinant tissue
plasminogen activator (rtPA) has
recently been used as a promising
therapy to reduce the risk of
vasospasm in patients operated on
within three days of subarachnoid
hemorrhage (10).

This report discusses our results in
treating 15 patients with an
intraoperative subarachnoid cisternal
injection of rtPA immediately
following intracranial aneurysm
clipping.

Patients and methods

Between July 1, 1991, and
December 1, 1992, a total of 33
craniotomies were performed at
Charleston Area Medical Center for
clipping of intracranial aneurysm.
Three craniotomies were done for

Figure 1. CT scans of patient with giant middle cerebral artery aneurysm and subarachnoid
hemorrhage pre-operative (left) and postoperatively (right) showing clearing of
subarachnoid blood following installation of rtPA. In addition, the figure at right
demonstrates the starburst artifact from the aneurysm clip on the right middle cerebral
artery aneurysm.

98 THE WEST VIRGINIA MEDICAL JOURNAL

Figure 2. Pre-operative angiogram of patient with giant middle cerebral artery aneurysm
seen on CT scan in Figure 1. There is very minimal evidence of vasospasm seen on this pre-
operative angiogram.

TABLE 1

PRE-OPERATIVE CLINICAL PATIENT GRADE [HUNT AND HESS (11)]

Rl'PA Group No RTPA Group

Grade I II III IV Grade I II III IV

Number of patients 3 6 4 2 Number of patients 0 6 2 1

TABLE 2

TIMING OF SURGERY FOLLOWING SUBARACHNOID HEMORRHAGE

RTPA Group

No RTPA Grouo

Days from bleed I

IV Days from bleed I II III IV

Number of patients 7

1 Number of patients 5 112

TABLE 3

TRAN SCRAN LAI. DOPLER VELOCITY (1-2 WEEKS POST SUBARACHNOID HEMORRHAGE)

RTPA Group No RTPA Group

Grade Normal Increased Grade Normal Increased

Number of patients 4 8 Number of patients 1 5

TABLE 4

OUTCOMES 6-24 MONTHS POST HEMORRHAGE

RTPA Group No RTPA Group

Good Fair Poor Dead Good Fair Poor Dead

Number of patients 7 5 12 Number of patients 5 2 0 2

incidental aneurysm repair and the
remainder following subarachnoid
hemorrhage. Transcranial doppler
studies were used to assess the degree
of cerebral vasospasm present both
before and after surgery in these two
groups.

After all of the patients underwent
CT scanning and cerebral angiography,
we performed craniotomy with
routine clipping of the intracranial

aneurysms. A total of 24 of these
patients with ruptured aneurysms
underwent craniotomy within four
days of subarachnoid hemorrhage. In
15 of these patients, rtPA was used as
an adjunct to subarachnoid clot
removal at the time of aneurysm
clipping.

In patients receiving tissue
plasminogen activator, 10 mg. of rtPA
was instilled into the intracranial

cavity in the region of the ruptured
aneurysm and basilar cisterns after
clip placement. Following a 15-minute
wait, one liter of saline was used to
irrigate the operative field and basilar
cisterns in order to clear the majority
of the rtPA and blood.

Results

The ages of patients in the two
groups were similar. Those not
receiving rtPA ranged from 33 to 66
years old, while those receiving rtPA
ranged between 34 to 65 years old.
The group not receiving rtPA
consisted of eight women and one
man, while there were 12 women and
four men who did receive rtPA.

The clinical grade of the patients at
the time of surgery was similar (Table
1). The timing of surgery was also
similar for both groups, with a
majority of patients undergoing
surgery within 48 hours of
subarachnoid hemorrhage (Table 2).

The results of transcranial doppler
studies carried out between one and
two weeks post subarachnoid
hemorrhage demonstrated normal
velocities in 17% of the patients
managed without rtPA and in 34% of
the patients receiving rtPA (Table 3).
Between six and 24 months following
craniotomy and treatment, a good to
fair result was seen in 77% of the
patients not receiving rtPA and in 80%
of the patients who received rtPA
(Table 4).

Discussion

The presence of subarachnoid
blood following aneurysmal rupture is
believed to be responsible to a great
degree for the appearance of delayed
cerebral ischemia from vasospasm (6).
Breakdown products of blood
including hemoglobin, free radicals
and prostaglandins have been felt to
play a role in the development of
vasospasm (12). Similarly, the volume
of blood seen on CT scan after
aneurysm rupture is believed to be
related to the risk of the development
of vasospasm and its complications
(13).

Theoretically, early removal of
subarachnoid blood should help
prevent cerebral vasospasm.
Previously, simple intraoperative
saline irrigation and dissection of the
subarachnoid space have been
attempted, but risk/benefit analyses
have proved inconclusive (14).

The fibrinolytic substance rtPA has
recently been shown to decrease
spasm following subarachnoid

MARCH 1994, VOL. 90 99

hemorrhage in animals (10). Findley
and colleagues reported the use of
intracisternal rtPA following
subarachnoid hemorrhage and early
surgery for intracranial aneurysm
clipping in 15 patients (15). They
demonstrated clearing of subarachnoid
blood on CT scans one day after
surgery, and only one patient
developed symptomatic vasospasm
and the only complication of epidural
hematoma was reported in this series.

In our study, essentially no
postoperative intracranial hemorrhagic
complications were seen, and as of
August 1993, a total of 121 cases have
been reported using rtPA as adjunctive
therapy for SAH (15,16,17,18,19,20). A
marked reduction in angiographic
vasospasm was seen in all of these
trials. Similarly, symptomatic
vasospasm was seen in only three of
these 121 patients. Despite these good
results, there has been one series with
a 20% mortality (16).

A trend towards reduction in
vasospasm as reflected in the
normalization of velocities of blood
flow seen on transcranial doppler
studies was observed in our patients
treated with rtPA. However, TCD
continued to show evidence of spasm
in 50% of the patients in this group
one to two weeks post SAH. Outcome
was the same in both groups. As
expected, poor grade patients of our
treatment groups had generally poor
outcomes.

Although small, our study suggests
there is no clear improvement in

patients treated with the intracisternal
injection of rtPA following early
craniotomy for aneurysm clipping as a
treatment for aneurysmal subarachnoid
hemorrhage. More study is needed
before this therapy will become a
standard.

References

1. Schochet SS Jr, WF McCormick. Essentials
of Neuropathology 1979:97.

2. Winn HR, AE Richardson, JA Jane. The
long-term prognosis in untreated cerebral
aneurysms. Part I: The incidence of late
hemorrhage in cerebral aneurysm: a ten
year evaluation of 364 patients. Ann Neurol
1977;1:358-70.

3. Pakarinen S. Incidence, aetiology, and
prognosis of primary subarachnoid
haemorrhage: A study based on 589 cases
diagnosed in a defined urban population
during a defined period. Acta Neurol Scand
[Suppl] 1967;29:1-128.

4. Kassell NF, Torner JC. Unpublished
observations. International cooperative
study on the timing of aneurysm surgery.
U.S. Public Health Grant No. IRION1590,
1982.

5. Allcock JM. Drake C. Ruptured intracranial
aneurysms - the role of arterial spasm. J
Neurosurg 1965;22:21-9.

6. Smith RR, J Yoshioka. Intracranial arterial
spasm: Neurosurgery 1985:2:1355.

7. Fayad PB, LM Brass. Chapter 5. In: Dopplei
ultrasonography in occlusive cerebrovascular
disease and brain ischemia. 1992:114.

8. Adams HP, Kassel NT, Torner JC, et al.
Predicting cerebral ischemia after
aneurysmal subarachnoid hemorrhage:
Influences of clinical condition, CT results,
and antifibrinolytic therapy. A report of the
Cooperative Aneurysm Study. Neurology
1987;37:1586.

9. Kassell NF, Peerless SJ, Durward QJ, et al
Treatment of ischemic deficits from
vasospasm with intravascular volume
expansion and induced arterial
hypertension. Neurosurgery 1982;11:337-43.

10. Findley JM, Weir BKA, Steinke D, et al.
Effect of intrathecal thrombolytic therapy on
subarachnoid clot and chronic vasospasm
in a primate model of SAH. J Neurosurg
1988;69:723-35.

11. Hunt WE, Hess RM. Surgical risk as related
to time of intervention in the repair of
intracranial aneurysms. T Neurosurg
1968;28:14-20.

12. Robertson JT. Cerebral arterial spasm:
Current concept. Clin Neurosurg 1974;21:
100-6.

13- Fisher CM, Kistler JP, Davis KM. Relation of
cerebral vasospasms to subarachnoid
hemorrhage visualized by computerized
tomographic scanning. Neurosurgery 1980;6:1.

14. Weir B. The effect of clot removal on
cerebral vasospasm. In: Neurosurgery
Clinics of North America. April 1990; 1(2).

15. Findley JM, Weir BK, Kassell NF, et al.
Intracisternal recombinant tissue
plasminogen activator after aneurysmal
subarachnoid hemorrhage. J Neurosurg
1991;75(2): 181-8.

16. Mizoi K, Takashi Y, Satoru F, et al.
Prevention of vasospasm by clot removal
and intrathecal bolus injection of tissue-type
plasminogen activator: preliminary report.
Neurosurgery 1991;28:807-13.

17. Zabramski J, Spetzler R, Lee S, et al. Phase I
trial of tissue plasminogen activator for the
prevention of vasospasm in patients with
aneurysmal subarachnoid hemorrhages. J
Neurosurg 1991;75:189-96.

18. Stolke D, Seifert V. Single intracisternal
bolus of recombinant tissue plasminogen
activator in patients with aneurysmal
subarachnoid hemorrhage: preliminary
assessment of efficacy and safety in an
open clinical study. Neurosurgery 1992,30:
877-81.

19. Ohman J, Servo A, Heiskanen O. Effects of
intrathecal fibrinolytic therapy on clot lysis
and vasospasm in patients with aneurysmal
subarachnoid hemorrhage. I Neurosurg
1991;75:197-201.

20. Mizoi K, Yoshimoto T, Takahashi A, et al.
Prospective study on the prevention of
cerebral vasospasm by intrathecal fibrolytic
therapy with tissue type plasminogen
activator. J Neurosurg 1993;78:430-7.

Manuscript Guidelines

All manuscripts should include:

1. Title page

2. An abstract of no more than 150 words

3. Text

4. Acknowledgements

5. References in parentheses numbered consecutively. No
more than 25 references will be published free of charge.

6. Tables

7. Legends for illustrations

All persons designated as authors should qualify for
authorship. Each author should have participated sufficiently
in the work to take public responsibility for the concept.

Where reference is made to generically-designated drugs,
the first such reference must be followed by parentheses
containing its most commonly known trade name.

All scientific material is reviewed by the Publication
Committee and should be sent to The Editor, West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.

100 THE WEST VIRGINIA MEDICAL JOURNAL

Spinal epidural metastases: A common
problem for the primary care physician

PHILLIP MCCALLISTER, M.D.

HOWARD H. KAUFMAN, M.D.

Department of Neurosurgery, Robert C. Byrd
Health Sciences Center of West Virginia
University, Morgantown, W. Va.

Abstract

Spinal metastases are a common
complication of cancer that should
be managed quickly and aggressively.
Most often from lung or breast
cancer ( or due to lymphoma ), they
usually seed from blood into
vertebrae and extend into the
epidural space. The most common
presentation is pain and weakness,
and the evolution can be rapid with
paraplegia within days. Better
prognosis is related to slower onset
and pretreatment motor status, so
spinal metastases are an
emergency. Testing includes X-rays,
neuroimaging, myelogram/CT and
most recently MRI. Treatment is
guided by the severity of
neurological deficits, whether
compression is by soft tissue or
bone, and the presence of instability.
A soft tissue mass with only mild to
moderate deficits can be treated
with radiation. Surgery’ is required
for severely affected patients who
are deteriorating rapidly with
instability and bone in the canal
New approaches and fusion
techniques facilitate decompression
and stabilization.

Introduction

There are approximately 365,000
cancer deaths per year in the United
States. This figure will undoubtedly
increase as the geriatric population
increases and the life expectancy of
cancer patients is prolonged due to
improved methods of therapy.

At postmortem exam, up to 70% of
the patients who die from cancer will
have spinal metastases. It has been
estimated that 5% of cancer patients
will develop epidural spinal cord
compression which translates into
about 18,000 cases of symptomatic
metastatic epidural spinal cord
compression per year.

In one autopsy series, meningeal
carcinomatosis occurred with a 4%
incidence, primarily due to leukemia,
lymphoma, and breast cancer. In

another series, there was a 2%
incidence of intramedullary metastasis.
Prompt and early diagnosis and
treatment are crucial to prevent pain
and progressive neurologic deficits in
such patients (1,2,3).

Bronchogenic carcinoma, carcinoma
of the breast, and lymphoma are the
most common spinal metastases due
to the prevalence of these tumors in
the general population (4,5).

However, the three cancers with the
highest incidence of metastasis are in
decreasing order multiple myeloma,
prostatic cancer and breast cancer. In
approximately 9% of these cases, the
primary malignancy is unknowm, and
in 8% of the cases, spinal cord
compression will be the first symptom
of cancer. The latent interval from the
diagnosis of cancer to the development
of spinal metastasis may be as long as
19 years, with breast cancer having
the longest latent interval (3,4,6).

The incidence of epidural spinal
cord compression involvement of a
certain region of the spine is related to
the number of vertebrae of that region
compared to the total number of
vertebrae and the size of the epidural
space at that region. The thoracic
spine is involved in about 59% of the
cases, the lumbar spine in 16%, the
cervical spine in 15%, and the sacral
spine in the remainder. A large
majority of the metastases localize to
one or two contiguous vertebral
levels. However, 17% of the patients
in one series showed evidence of
compression of the spinal cord or
cauda equina at two or more
non-contiguous sites at some time
during the course of their disease.

Metastases to the spine and the
extradural space occur mainly by
hematogenous spread via
paravertebral and extradural venous
plexi. As a general rule, the vertebral
body may be destroyed, but the
intervertebral disc is maintained
because it is resistant to invasion by
tumor. This can be useful in the
differential diagnosis between tumor
and infection since the latter involves
the disc.

Lymphomas enter the spinal canal
mainly by direct extension from the
adjacent retroperitoneal or mediastinal
lymph nodes via the intervertebral
foramina (3, 4, 7, 8). Neuroblastomas
also enter the epidural space through

the intervertebral foramina. The dura
matter is an effective barrier to the
penetration of tumor cells into the
subdural or subarachnoid space, a
reason to avoid opening the dura at
the time of surgery (2).

Presentation

Pain is the cardinal symptom of
spinal tumors and the initial symptom
of 96 percent of the cases. Pain
precedes other symptoms by five days
to two years with a median time of
seven weeks. It may be local in the
area of spinal involvement, radicular
along the dermatome or sclerotome
supplied by the root involved, or
funicular along the distribution of the
spinal tracts which are compressed
(and typically described as a tight or
cold sensation).

Spinal pain is non-mechanical in
nature, which means it is present
when the patient is not moving. The
characteristic spinal pain due to
metastatic disease is dull. It increases
with time, requiring increasing dosage
and potency of analgesics. It is
exacerbated at night when the patient
is supine. Activities producing a
Valsalva maneuver will also often
increase the pain (2,3,5,6,9,10.11,12,14).

The pathogenesis of pain can be
attributed to bony destruction with
periosteal distention, instability,
pathologic fracture, or compression of
spinal cord or root. Pain conducting
fibers are located in the anterior and
posterior spinal ligaments, the fibrous
capsule surrounding the intervertebral
disc and the dura. Stretching or
compression will excite these nerve
fibers. Direct compression of the cord
causes little pain, but direct
compression of the nerve roots may
cause severe radicular pain (12,13).

At the time of diagnosis, 76% of
patients complain of weakness and
86% exhibit muscle weakness on
clinical examination. Sensory
disturbances such as numbness or
paresthesias are noted by 51% of
patients, but sensory deficits were
found in 65% of patients on
examination. Bowel and bladder
dysfunction did not occur as a
presenting complaint in several major
series. However, 57% of patients had
urinary retention. Fifteen percent of
patients did not present until

MARCH 1994, VOL. 90 101

paraplegic in spite of prior spinal or
radicular pain (3,12,14).

Several syndromes are related to
spinal metastases including:

1. Horner’s Syndrome -

Characterized by miosis,
pseudoptosis, apparent
enophthalmos, and dryness of
the skin over the face. This
occurs due to involvement of
the paraspinal sympathetic
chain.

2. Pancoast’s Syndrome -

Characterized by motor
weakness and pain in the
distribution of the C-8 and T-l
nerve roots, as well as Horner’s
Syndrome, which results from
involvement of the inferior cord
of the brachial plexus due to
tumor mass of the superior
pulmonary sulcus.

3. Pain in the thoracic region -
Mimics anginal pain and radiates
anteriorly unilaterally or
bilaterally.

4. Pain of the lumbar spine -

Resembles an acute abdominal
pain and radiates into the
anterior abdominal wall.

5. Herpes zoster - Several authors
have reported that the eruption
of zoster will presage an episode
of spinal cord compression at
the same level. Other authors
consider that the virus in the
dorsal root ganglion is activated
by tumor invasion.

6. Brown-Sequard Syndrome -
Characterized by ipsilateral
weakness, position loss,
contralateral pain and
temperature impairment.

Signs

Signs of cord compression are
generally symmetric, while those of
radicular compression are generally
asymmetric. Compression of the cord
produces a myelopathy with
weakness and spasticity below the
level of the lesion, sensory loss, and
often bowel and bladder dysfunction.
Early signs of anterior compression
may manifest as motor weakness,
impairment of pain sensation
(spinothalamic tract and anterior
lateral corcf), but intact touch and
position sense (posterior columns).

In the thoracic spine, the level of
sensory loss is the only way to
localize the level of involvement. The
cord level is generally one to two
levels below the vertebrae involved
(since cord levels are higher) (4,5,12).

In situations of chronic compression,
spasticity, hyper-reflexia and extensor
plantar response are found, whereas
in acute compression, all reflexes
below the level of the lesion are
usually absent due to spinal shock.
The loss of abdominal reflexes, which
come from T8 to T12, are useful for
localization. Saddle anesthesia, loss of
bowel and bladder control and plantar
extensor reflex should alert one to
compression of the cauda equina or
conus medullaris (4,12).

Prognosis

Important detenninants of functional
prognosis in patients with spinal
metastasis are:

1. Pretreatment neurologic status;

2. Tumor biology, i.e. the natural
history of the systemic
malignancy;

3. Location of the tumor in the
spinal canal; and

4. The kind of therapy employed
(3, 5, 6, 7).

There is a strong correlation
between the pretreatment motor status
and the functional outcome since
60%-70% of the patients who could
walk at the time of diagnosis will
retain the ability to walk after
treatment (6). This is in contrast to
those who were paraparetic, of whom
only 35% retained the ability to walk
after treatment, and the fact that 28%
of these patients become paraplegic in
less than 24 hours.

The percent of patients who are
paraplegic and regain the ability to
walk varies from 0% to 25%,
depending on the series. Gilbert
reports a 5% recovery, White reports a
10% recovery, and Livingston and
Perrin report the highest rate of
recovery at 25%. But, the success rate
in these studies depended upon the
definition of “plegia.” In some series,
this meant loss of all cord function,
while in others it included some
preservation of neurologic function.

Of the patients with some neurologic
function, 20% - 25% regain ambulatory
status as opposed to none of the
patients without neurologic function
pretreatment (1,3,6,15).

The rate of onset and duration of
symptoms is also of value for
prediction. A rapid onset of symptoms
holds a poorer prognosis than one of
slow progression. Once paraplegia
has appeared, the duration of
paralysis also has prognostic
significance. Twenty percent of
patients who are paretic greater than
24 hours regain ambulation, whereas

0% who are paraplegic for greater
than 24 hours regain the ability to
ambulate. In addition, patients who
have lost bowel and bladder function
have a poorer prognosis than those
with function intact.

The biological activity of the tumor
is another important determinant in
the neurological outcome. Tumors
with a favorable prognosis are
myeloma, lymphoma, Ewing sarcoma,
neuroblastoma and carcinoma of the
breast. Bronchogenic carcinomas
generally do poorly. The prognosis of
many tumors is also related to their
radiosensitivity (3,6).

The segment of the spinal cord at
which the epidural mass is located has
been related to functional outcome.
This is due to the variable density of
radicular arteries and, therefore,
collateral circulation. The collateral
supply is poorest in the upper three
cervical segments, at T-4, and at L-l.
Interference with blood flow at these
levels due to compression is more
likely to result in ischemic necrosis.
Tumors which are located posteriorly
have a better functional prognosis
than those which are located
anteriorly.

Pathophysiology

The epidural space is defined by
the periosteum of the vertebral canal,
ligamentum flavum and the dura of
the spinal cord. It is a true space with
no lymphatic channels or lymph
nodes that is filled with loose areolar
tissue, arteries, veins, and connective
tissue. The high incidence of vertebral
body metastasis is thought to be due
to the valveless epidural venous
plexus of Batson, which also drains
the vertebral bodies, allowing
bidirectional flow and direct
communication with the thoracic and
pelvic venous systems (2).

Epidural tumors cause obstruction
of the epidural venous plexus (8) and
the resultant back pressure enhances
the production of vasogenic edema.
This edema involves the white matter
and ultimately spreads to the grey
matter in the later stages of compression.
The blood flow to the spinal cord is
diminished due to this stasis (2).

In addition, the neural tissue is also
deformed by the epidural mass. The
ability of the spinal cord to adjust to
these forces is determined by the rate
of compression and the level of the
spinal cord at which the compression
is located. This is related to the
density of radicular arteries and,
therefore, collateral circulation which
varies at different levels of the spinal

102 THE WEST VIRGINIA MEDICAL JOURNAL

cord (2,8).

As previously mentioned, collateral
supply is poorest in the upper three
cervical segments, at T-4, and at L-l.
Decompensation from compression
and accompanying decreased blood
flow may occur in hours or days from
the time the signs of compression
have become manifest. This ischemic
insult can cause irreversible loss of
function if the compression is not
alleviated rapidly.

In an experimental study, it was
shown that edema is associated with
PGE-2 production. Dexamethasone
fails to decrease PGE-2, whereas
methylprednisolone and indomethacin
do decrease production. It is not clear
if the decrease in edema correlates
with delay in the onset of paraplegia.
Dexamethasone and indomethacin
correct the specific gravity abnormalities
after 30 hours of treatment, and both
delay the onset of paraplegia, whereas
methylprednisolone does neither. The
clinical efficacy of pharmacologic
agents seems to relate to spinal cord
specific gravity and not to edema (6).

Laboratory tests

A complete blood count should be
done on all patients. Anemia can be
seen due to blood loss from
gastrointestinal cancers or from
decreased production due to renal cell
carcinoma. Leukopenia, anemia, and
thrombocytopenia indicate the possibility
of bone marrow involvement (10,12).

The prothrombin time (PT) should
be checked. Prolongation suggests
liver involvement with tumor, and
until corrected would increase the risk
of surgery (12).

An electrolyte panel will indicate
volume status, renal failure, and acid
base status. An elevated calcium
suggests widespread bony metastasis.
Total protein and globulin indicate a
patient's nutritional state and, if the
globulin fraction is elevated, multiple
myeloma should be suspected and
protein electrophoresis and Bence
Jones proteins ordered. Uric acid will
be elevated in those patients with
hematologic malignancies. Liver
enzymes (gamma glutamyltransferase,
aspartate aminotransferase, alanine
aminotransferase, alkaline phosphatase)
should be checked to look for liver
metastasis (12).

Serum tumor markers are useful in
the evaluation and in the follow-up of
malignancy. Prostate cancer is
associated with a rise of the serum
acid phosphatase or prostatic specific
antigen. Carcinoembryonic antigen
(CEA) is typically elevated with cancer

of the colon, but it may also be
elevated with other solid tumors. Beta
human chorionic gonadotropin or
alpha fetoprotein may be found in
testicular or ovarian carcinomas.

Serum catecholamines, vanillymandelic
acid or homovanillic acid, may be
elevated in patients with neuroblastoma
or pheochromocytoma (12).

CSF should be obtained at
myelography and be sent particularly
for protein and millipore filter. Protein
is elevated in patients with epidural
spinal cord compression. CSF for
millipore filter is used for the
evaluation of leptomeningeal
carcinomatosis, although the initial
cytology is positive in only 60% of
patients with leptomeningeal disease
(12).

Diagnostic imaging

Plain X-ray films should be
obtained if metastatic spine disease is
suspected since abnormalities will
show up in 60% of these cases on this
medium. Physicians must remember
that vertebra must undergo about 50%
decalcification in order for lesions to
be visualized by plain X-rays, and
early lesions may not be seen.
Complete evaluation of the spinal axis
should be performed since in
approximately 17% of the cases,
multiple metastases are found.
Radiographic signs of tumor include
destruction of the pedicles, partial or
complete collapse of a vertebra,
osteoblastic infiltration of vertebra, or
paraspinous soft tissue mass
(2,5,7,8,12).

Bone scans are useful in the
detection of metastases in the axial
and appendicular skeleton. Bone
scans are positive in 36% of patients
in which plain films were negative.
Plain radiographs may lag three
months to 18 months behind bone
scans in the detection of a tumor.

Bone scans have the disadvantage of
lacking the specificity of plain
radiographs, CT and MRI. In addition,
trauma, infection, and degenerative
disorders will cause false positives,
and multiple myeloma and thyroid
carcinoma consistently fail to be
detected by bone scans (2,5,12).

The most commonly used
radiologic study to demonstrate spinal
cord and root compression has been
myelography followed by CT.
Myelography will demonstrate the
level, the extent of the mass, and if it
is intradural or extradural. CT exam of
the areas of block or compression are
essential to delineate in greater detail
the extent and location of the

vertebral involvement and the
position of the mass in relation to the
spinal cord.

In evaluating metastatic spine
disease by myelography, it is essential
to visualize the upper limit of the
block. A second puncture at the C-l
C-2 interspace may be necessary if
dye does not flow from below.
Another technique to visualize the
rostral extent of the block is to
perform a delayed CT scan
approximately one hour after the
initial CT. Neurologic status may
deteriorate after myelogram due to
downward herniation of the cord
because of reduction of CSF pressure
below the lesion. Therefore,
consultation with a neurosurgeon
prior to myelography is prudent
(2,5,10,12,16).

If the myelogram is negative in a
cancer patient with neurological
symptoms, meningeal carcinomatosis,
carcinomatous myelopathy and
carcinomatous neuropathy must be
considered. If the patient has received
radiation therapy, then radiation
myelopathy must be considered. This
can occur as early as several weeks
after therapy, but usually it is seen
nine months to 24 months after
completion of treatment. Other
possible causes of cord syndromes
that should be considered include
multiple sclerosis, amyotrophic lateral
sclerosis, or transverse myelitis of
unknown etiology (2,4,12).

MRI is becoming the current study
of choice for spinal cord compression
in some centers because it is non-
invasive and does not expose the
patient to ionizing radiation. T-l
weighted images demonstrate
excellent anatomic detail of the spinal
cord and bone marrow of the
vertebral body. The disadvantages of
MRI include accessibility and the
length of scan time the patient must
remain motionless. T-2 weighted
images demonstrate disc space and
subarachnoid space. Tumors show
decreased signal intensity on T-l and
increased intensity on T-2 weighted
images. MRI also allows the cephalad
and caudad extent of the tumor to be
visualized (2,l6).

There have been comparisons
between MRI and myelography.
Smoker and colleagues reported a
series of 22 patients in which
myelography, CT-myelography, and
MRI were compared in the diagnosis
of epidural metastasis. Myelography
was diagnostic in 16 of the 22 cases,
and MRI was diagnostic in 19 of the
22 cases. In a study of 19 patients

MARCH 1994, VOL. 90 103

with systemic cancer who were being
evaluated for back pain or
myelopathy, Hagenau and co-workers
demonstrated small clinically
significant epidural lesions in nine of
the 19 patients which were not
demonstrated by MRI.

In spite of the fact that lumbar
puncture is still needed for CSF
examination for diagnosis of
leptomeningeal carcinomatosis, MRI
will likely continue to increase in its
role for the evaluation of metastatic
spinal disease (2,7,12).

Non-operative care

Management of epidural spinal
tumors must be based on the
individual patient and the factors that
must be considered include:

1. The patient’s neurologic
condition;

2. Tumor biology;

3. The site of involvement of the
tumor;

4. The rate of progression of
symptoms;

5. The general medical condition
of the patient; and

6. The age of the patient (6,17).

Corticosteroids are efficacious in the
management of epidural tumors with
cord compression and they act by
relief of vasogenic edema. In certain
tumors of the round cell variety
(lymphoma and neuroblastoma),
evidence exists that steroids have an
oncolytic effect. However, there are
potential side effects of steroids
including gastrointestinal bleeding,
steroid myopathy, hyperglycemia
(especially in known diabetics),
interference with anticonvulsants,
poor wound healing, infection and
pseudorheumatism from too rapid of
a taper. The majority of these side
affects occur after the patient has
been on steroid therapy for periods of
greater than one month (10).

Once the diagnosis of epidural
tumor has been made, most
physicians agree that radiation therapy
is the first choice of treatment. As a
general rule, one-third to one-half of
the patients treated with radiation
therapy will improve and remain
neurologically stable at the end of one
year, 60% will obtain pain control,
and 30% will be able to discontinue
narcotics. Patients with breast,
prostate, and hematogenous tumors
are most likely to respond favorably
to radiation therapy alone.

A major complication of radiation
therapy is radiation myelopathy. This

is not a problem with the patient who
has a limited life expectancy, but it is
a concern for the patient with a
favorable prognosis. Radiation
myelopathy is not related to the total
dose, but rather to the treatment time
and the total number of fractions
used.

Deterioration while undergoing
radiation therapy may reflect
radioresistance or compression as a
result of vertebral collapse.
Experimental studies do not support
the concept of edema induced from
radiation as a cause for neurologic
deterioration. When used after
surgery, the major problems include
poor fusion when bone graft has been
used, poor wound healing, and
sepsis, especially when the patient is
also taking steroids (3,5,6,10,13).

The use of specific chemotherapy is
best determined by the oncologist.

The advantages of chemotherapy
prior to surgery are the reduction of
the tumor mass, as well as the early
treatment of micrometastasis.

Surgery

Indications for surgical intervention
for epidural metastasis include the
need to make histologic diagnosis,
spinal instability, compression by
bone in the spinal canal, recurrent
tumor when no additional radiation
therapy can be given, radioresistant
tumor, and neurologic deterioration
while undergoing radiation therapy
(13,14,17). The traditional approach
was laminectomy followed by
radiation therapy, but the outcomes of
this approach were not superior to
radiation therapy alone. As a result,
there are still many physicians who
favor steroids and radiation therapy as
the initial treatment of choice.

Reasons for past surgical failures in
the treatment of epidural metastasis
include non-selective use of a single
surgical approach, insufficient surgical
resection of tumor and bone, failure
to stabilize, and intradural extension
of the tumor. In view of the recent
articles about the variety of approaches
which can be used to tailor the
surgery to the location of the tumor,
the role of surgery as a procedure
of diagnosis or salvage must be
re-evaluated (2,3,6, 1 3, 14, 17, 18).

The patient’s preoperative
neurologic condition is the most
important pretreatment variable in
relation to his/her surgical outcome.
Surgery should be reserved for those
patients who still retain some degree
of motor function. It is not considered
beneficial for patients who are

paraplegic or near paraplegic after
aggressive decompression and
instrumentation, or who have a
rapidly evolving deficit over the prior
24 hours in the face of steroids.
However, patients who develop
paresis or plegia slowly may benefit
from anterior decompression (6,13).

Patients with cord compression
from bone (after collapse or
deformity), spinal instability due to
tumor erosion, and those who
deteriorate while undergoing radiation
therapy are surgical candidates if their
life expectancy is greater than six
weeks (13). Laminectomy is still the
procedure of choice if the tumor is
located posterior or posterolateral
(situated between the cord and the
ligamentum flavum) (10).

Eighty-five percent of epidural
tumors arise in the vertebral body and
invade anteriorly and remain anterior.
The anterior approach has become
the gold standard for such tumors
because it permits adequate exposure
and visualization of the extent of the
tumor, allowing for aggressive and
extensive decompression. The anterior
approach also allows for anterior
stabilization and does not disaipt the
posterior column, which is still intact
in the majority of instances.

In the thoracic spine, direct anterior
resection of the tumor with
stabilization can achieve the goals of
decompression and stabilization. This
approach is also useful in that it
allows better exposure for resection of
paravertebral soft tissue masses
(3,6,8,9.14,15,17,19). An anterolateral
approach with vertebral body
resection can also be used when the
involvement is predominately anterior.

There are the following circumstances
in which it is advantageous to utilize
the posterolateral approach:

1. It is better tolerated by patients
whose medical condition would
prohibit the use of an anterior
approach;

2. It allows access to the spine
when all three columns are
involved;

3- Posterior instrumentation can be
incorporated with relative ease;

4. It allows better access if the
major portion of the tumor is
posterior and lateral; and

5. It allows access if there is
multilevel involvement which is
discontinuous. This approach is
not suitable for the
cervicothoracic and the
lumbosacral junction; and it is
not recommended when an

104 THE WEST VIRGINIA MEDICAL JOURNAL

anterior approach can be
performed since the posterolateral
approach does not allow the
exposure for resection.

Following treatment by this
method, the ambulatory rate is
65% with a gain of ambulation
of 28% (20).

Of the patients with ventral tumor,
9% to 16% of them remained ambulatory
if decompressed posteriorly. In
addition, 30% to 50% of the patients
with posterolateral tumors remained
ambulatory if decompressed
posteriorly, whereas 70%-80% of the
patients with anterior compression
remained ambulatory if decompressed
anteriorly (3,6).

Posterior stabilization may be
required in conjunction with surgical
decompression if there is instability'.
Instability is defined in cancer as a
translational deformity, three column
involvement of the spine, loss of
vertebral height of greater than 50%,
or pain which is exacerbated by
movement. At times, stabilization
alone may be performed in patients
who develop instability and pain after
undergoing successful treatment of
tumor by radiation or chemotherapy.

Posterior stabilization can be
performed with plates, screws, rods,
steel rectangles, and wires. The choice
of the exact type of posterior
stabilization depends on the region of
spine involved, the number of levels
involved, the number of columns
involved, and the surgeon’s
preference (1,6,10,13,21,22,23).

After spinal surgery, patients should
be monitored carefully due to the risk
of neurological deterioration,
cardiopulmonary complications,
sepsis, deep vein thrombosis and
subsequent pulmonary emboli, and
the fact that they are often
immunosuppressed and in poor
medical condition.

Conclusion

Epidural spinal cord compression
from metastatic disease is a problem
which will face physicians in all types
of practices with increasing frequency.
Thus, it is important for the physician
to be aware of the history and
physical findings seen in this disease
entity.

Once the physician suspects
metastatic disease to the spinal
column with or without spinal cord
compression, it is imperative that
he/she be sensitized to the risk of
rapid progression and the need for
immediate diagnosis and treatment.
The neurosurgeon should be involved
early and to help plan diagnostic
studies and treatment.

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Spatz H. Spinal metastases as the first
manifestation. In: Piotrowski W. Brock M,
Klinger M, editors. Advances in
neurosurgery. Berlin: Springer-Verlag,
1984:44-46.

15. Siegal T. Tiqva P, Siegal T. Vertebral body
resection for epidural compression by
malignant tumors. J Bone Jt Surg 1985;67-A:
375-82.

16. McLain RF, Weinstein JN. Tumors of the
spine. In: Garfin SR, Wiesel SW, editors.
Seminars in spine surgery. Philadelphia:
Saunders, 1990:2, :157-80.

17. Lee CK, Rosa R, Fernand R. Surgical
treatment of tumors of the spine. Spine,
1986; 11:201-8.

18. Moore AJ, Uttley D. Anterior decompression
and stabilization of the spine in malignant
disease. Neurosurgery 1989;24:713-17.

19. Cybulski GR. Methods of stabilization for
mestatic disease of the spine. Neurosurgery
1989;25:240-52.

20. Perrin RG, McBroom RJ. Surgical treatment
for spinal metastasis: the posterolateral
approach. In: Sundaresan N, Schmidek HH,
Schiller AL, Rosenthal DI, editors. Tumors
of the spine; diagnosis and clinical
management. Philadelphia: Saunders, 1990;
305-15.

21. Lesoin F, Kabbaj K, Debout J, Jomin M,
Lacheretz M. The use of Harrington’s rods
in metastatic tumours with spinal cord
compression. Acta Neurochir 1982;65:175-
81.

22. Gilbert RW, Kim JH, Posner JB. Epidural
spinal cord compression from metastatic
tumor: diagnosis and treatment. Ann Neurol
1978; 3:40-51.

23. Tolli TC, Cammisa FP, Lane JM. Metastatic
disease of the spine. In: Garfin SR, Wiesel
SW, editors. Seminars in spine surgery.
Philadelphia: Saunders, 1990;2:181-176.

IllilM

MARCH 1994, VOL. 90 105

Geophagia in a chronic hemodialysis patient

JAMES P. GRIFFITH, M.D.

Assistant Professor of Internal Medicine and
Psychiatry, Department of Internal Medicine
and the Department of Behavioral Medicine
and Psychiatry
VEENA K. BHANOT, M.D,

Associate Professor of Psychiatry, Department
of Behavioral Medicine and Psychiatry

West Virginia University School of Medicine,
Charleston Division; and Charleston Area
Medical Center, Charleston, W. Va.

Abstract

Geophagia, the deliberate
ingestion of earth, is a serious
clinical problem, particularly for
dialysis patients. This article
presents a geophagic patient with
end stage renal disease and reviews
the etiology, consequences and
treatment of this disorder.

Introduction

The practice of geophagia by
dialysis patients may lead to significant
morbidity and mortality. Life-threatening
hyperkalemia has been previously
described as a consequence of
geophagia in patients with chronic
renal failure (1).

In this article, we describe a patient
with chronic renal failure on hemodialysis
who was unique in that she ingested
common sedimentary sandstone — not
clay, dirt or pebbles as reported in
other cases of geophagia (2-5). This
patient is a West Virginia native, who
is the first reported case from the
Charleston area. Her craving for the
stone was related to both nutritional
and psychological variables, and
this article discusses the etiology,
consequences, and possible therapeutic
interventions for geophagic patients.

Case report

A 29-year-old black female with end
stage renal disease revealed her habit
of geophagia to her physicians during
her most recent hospitalization at the
Charleston Area Medical Center. She
had begun eating foreign materials
soon after hemodialysis was instituted,
first trying green apples and clay
before settling on sandstone. No other
family members or acquaintances
practiced geophagia.

Almost every day, this patient had
been eating 100 grams to 300 grams of
sandstone, which she described as

pleasurable because of both its taste
and “crunchy” texture. She said she
occasionally baked the sandstone in
the oven and her craving for it was
strongest when she felt frustrated,
stressed at home, or sexually aroused.
The craving diminished after blood
transfusions and was unrelated to
dialysis treatments.

Her psychiatric history included
intermittent depressive episodes,
neuropsychiatric manifestations of her
systemic lupus erythematosis
(inappropriate affect, visual and tactile
hallucinations), and occasional
euphoria secondary to steroid therapy.
During this admission, she remained
somewhat depressed regarding her
poor health. She also admitted
embarrassment, shame, and sadness
regarding her geophagia, which she
did not understand and could not
control.

Pertinent history included a
microcytic, hypochromic anemia
which developed in 1982, antedating
the onset of complete renal failure and
geophagia by approximately one year.
She had remained chronically anemic
with normal RBC indices and was
maintained on ferrous sulfate (650
mg./day), receiving many intermittent
transfusions. At the time of this
admission, her laboratory data
included Hb.=5.8 gm./dl., Hct.=17,
Na=136, K=8.1, Cl=100, CO?=21,
BUN=108, Cr=18.2, and Glu=94.

Further workup for geophagia
included a normal serum iron (128
mcg./dl.), TIBC (330 mcg./dl.), serum
zinc (75 mcg./dl.) and serum copper
(107 mcg./dl.). Her stool was heme
negative and an abdominal X-ray
showed abundant fecal material in the
colon and a small calcified phlebolith.
She was started on psychotherapy with
positive reinforcement and was also
encouraged to constmct barriers to
decrease availability of the sandstone,
and her iron therapy was to be
continued.

Discussion

Although cultural influences are
clearly responsible for the practice of
geophagia in many instances (2,6-8),
our patient reported no previous
exposure to the habit of geophagia or
pica through friends or relatives. Her
geophagia could, therefore, not be
traced to any factors related to her
environment from birth to the present.

There are also nutritional theories
concerning the etiology of geophagia
which center around deficiencies of
iron (9-1 T) and zinc (12,13) as a cause
of pica in children, although the
relationship of zinc deficiency to
geophagia is unclear (14). Our patient
was clearly anemic prior to the onset
of her geophagia, however, her habit
of geophagia did not develop until
one year later. She remained
geophagic and anemic despite iron
therapy and normal serum iron and
TIBC. This fact, as well as the
subjective decrease in the craving
following transfusions, may support a
etiologic relationship between the
anemia (rather than an iron deficiency)
and geophagia. This is contrary to
previous reports which conclude that
geophagia is related to iron deficiency
as demonstrated by decreased
geophagia with iron therapy prior to
correction of the anemia (10,11). In
addition, our patient demonstrated
normal serum zinc, so this factor did
not seem related to her geophagia.

Psychological factors have been
implicated as potential causes of pica
in general, of which geophagia is a
subset. Studies of pica in children
suggest numerous theories including
oral fixation, desire to chew solids
(15), as well as craving the taste, color,
or texture of the substance eaten (6).

In one study, maternal deprivation,
parental neglect, and poor parent-child
relations were among the factors
found to be more prevalent among
children with pica (16).

Our patient reported a strong
craving for the taste and texture of the
substance, which was stronger at times
of stress (she is unemployed living on
a fixed income, undergoing
hemodialysis, divorced, supporting
one child, and living in public
housing.) Depression about her
chronic illness and feelings of
inadequacy regarding her parental
abilities and financial resources
contributed to her geophagic craving.
She also reported that sexual arousal
heightened her craving and increased
her geophagia.

Metabolic consequences of
geophagia include hypokalemia (17)
and hyperkalemia (1), and decreased
serum levels of minerals such as iron
and zinc (18). Other complications
have included rectal bleeding (5),
colonic obstmction and perforation (2),
parasitic infestation, constipation (6),

106 THE WEST VIRGINIA MEDICAL JOURNAL

allergic reaction (19), increased
incidence of toxemia in pregnancy (20),
and maternal death (21). Also
syndromes of hypogonadism,
hepatosplenomegaly, and iron
deficient anemia (22), as well as
cachexia africanus (23) have been
reported.

Our patient’s anemia was attributed
to chronic renal failure and systemic
lupus erythema tosis. She had no
complaints of constipation or
abdominal pain and no dental injuries
from eating the sandstone. She had
experienced only one recent episode
of hyperkalemia and this condition did
not seem to be a recurrent problem.
The psychological effects reported by
this patient included severe
embarrassment, shame, anxiety and
reclusiveness in an attempt to conceal
her behavior. Her relationships with
family and friends had deteriorated
because they regarded her geophagic
behavior as quite bizarre.

Therapy for geophagia can be
divided into two categories: nutritional
and psychiatric. Nutritional therapy
centers around supplementation of
minerals — primarily iron and zinc.
Therapy with iron in patients who are
iron deficient has successfully
terminated the behavior (10,24). Zinc
therapy of pica in children has been
successful in patients found to be zinc
deficient (12,13). Our experience with
this case suggests correction of any
anemia as a useful modality for
lessening geophagia.

Behavioral techniques in the past
have been based upon actual physical
restraint, though this was frequently
unsuccessful (6). Techniques of
negative reinforcement for practicing
geophagia and positive reinforcement

for refraining from geophagia are
current techniques being employed (6).
The necessity to eliminate
“psychological stress” has been
pointed out by previous authors as an
important aspect of complete
management of children with pica (16).

Conclusion

When called to evaluate dialysis
patients with periodic hyperkalemia or
acute neuropsychiatric changes, the
psychiatric consultant should inquire
about geophagia. To help establish the
etiology of geophagia, a thorough
history should be taken, clinical
presentations must be reviewed, and
an appropriate laboratory workup be
conducted. An understanding of the
interplay between psychological and
physiological factors is helpful in
managing geophagic patients and may
reduce their morbidity and mortality.

Acknowledgements

The authors wish to express their
appreciation to Dr. Frank J. Ayd Jr.,
M.D., for his editorial assistance, and
to Mrs. Jodi Asbury for her secretarial
assistance.

References

1. Gelfand MC, Zarate A, Knepshield JH.
Geophagia - a cause of life threatening
hyperkalemia in patients with chronic renal
failure. JAMA 1975;234(7):738-40.

2. Bateson EM, Lebroy T. Clay eating by
aboriginals of the Northern Territory.

Medical Journal of Australia 1978; 10 Suppl
1(1): 1-3-

3. Litt AS. Pica in dialysis patients. Dialysis and
Transplantation 1984; 13(12):764-5.

4. Okcuoglu A, et al. Pica in Turkey I. In: The
incidence and association with anemia.

Amer J of Clinical Nutrition 1966;125-31-

5. Robertson W, Crabtree JB. Pebble ingestion:
An unusual form of geophagia. Southern
Medical Journal 1977;70(7):776,792.

6. Danford DE. Pica and nutrition. Ann Rev
Nutr 1982;2:303-22.

7. Halsted JA. Geophagia in man: its nature
and nutritional effects. Perspectives in
Nutrition 1968;21(12):1384-93.

8. Vermeer DE, Frate DA. Geophagia in rural
Mississippi: environmental and cultural
contexts and nutritional implications. Amer
Journal of Clin Nutr 1979;32:2129-35.

9. Ansell JE, Wheby MS. Pica: its relation to
iron deficiency, a review of the recent
literature. Virginia Medical Monthly 1972;
99:951-4.

10. Crosby WH. Pica. JAMA 1976;235(25):2765.

11. Crosby WH. Clay ingestion and iron
deficiency anemia (letter). Annals of Internal
Medicine 1982;97(3):456.

12. Karayalcin G, Lanzkowsky P. Pica with zinc
deficiency (letter). Lancet 1976;2(7987):687.

13- Hambidge KM, Silverman A. Pica with rapid
improvement after dietary zinc supplementation.
Arch Diseases of Childhood 1973;48:567-8.

14. Halstead JA, Ronaghy HA, Abadi P. Zinc
deficiency in man: The Shiraz Experiment.
Amer J of Medicine 1972;53:277-84.

15. Neuman HH. Pica - Symptom or vestigal
instinct? Pediatrics 1970;46:441-4.

16. Singhi S, Singhi P, Adwani GB. Role of
psychosocial stress in the cause of pica.
Clinical Pediatrics 1981;20(12):783-5.

17. Gonzalez JJ, Owens W, Ungaro PC, Werk
EE Jr., Wentz PW. Clay ingestion: a rare
cause of hypokalemia. Annals of Internal
Medicine 1982;97(l):65-6.

18. Danford DE, Smith JC Jr., Huber AM. Pica
and mineral status in the mentally retarded.
Amer J of Clinical Nutrition 1982;35:958-67.

19. Krengel B, Geyser F. Chronic pica in an
adult (letter). South Afr Med J 1978,53(13):
480.

20. O'Rourke DE, Quinn JG, Nicholson JO, Gibson
HH. Geophagia during pregnancy. Obstetrics
and Gynecology 1967;29(4):581-4.

21. Key TC, Horger EO, Miller JM. Geophagia as
a cause of maternal death. Obstetrics and
Gynecology 1982;60(4):525-6.

22. Cavdar AO, Arcasoy A. Hematologic and
biochemical studies of Turkish children with
pica. Clinical Pediatrics 1972; 1 1(4):215-23-

23- Mustacci P. Cesare Bressa (1795-1836) on
dirt eating in Lousiana. JAMA 1971 ;218(2):
229-32.

24. Lanzkowsky P. Investigation into the
etiology and treatment of pica. Arch
Diseases of Childhood 1959;34:140-8.

MARCH 1994, VOL. 90 107

THE

JAMES

THE

That’s why the planners of
The Arthur G. James
Cancer Hospital and
Research Insti-

tute, a National

\ NationalCancer Institute Designated

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sciences, pharmacy
and veterinary med-
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efforts to advance efficiently
while benefiting from the
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OHIO

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Too often government leaders act as
if change will not occur unless they
intervene with new laws and
regulations. The health care delivery
system in West Virginia is a perfect
example of how changes can occur
without legislation.

What am I talking about? The rate of
rise in medical expenditures in the
state has slowed to 6%-8% as
compared to 14% a year ago. In some
areas of West Virginia, over 80% of the
individuals with medical insurance
are covered by a plan that sets
reimbursement rates and limits
out-of-pocket expenses. In almost
every part of the state, established
health care delivery networks are
expanding and new networks are
being explored or developed. In
addition, a rural health initiative is
exposing young physicians,
pharmacists, nurses, and other health
care professionals to patient care in
rural areas.

How can all of these positive
actions have taken place without
legislation? One reason is that
physicians and patients have been
working together in several areas of
the state to improve their health care

President's ?age

To legislate or not to legislate?

delivery systems. A second important
factor is that hospitals and physicians
have been interacting to create
networks with businesses and
consumers. Another critical reason is
that doctors, nurses, hospital
employees, secretaries, bankers,
accountants and people in all segments
of society are working to staff free
clinics for the indigent. The bottom
line is that throughout West Virginia,
medical and non-medical groups are
talking and taking actions to improve
the way we deliver health care in the
state.

So, the question remains - Do we
need to legislate major changes in
health care or not? In West Virginia,
we now have spent more than two
sessions of the Legislature debating
this subject. Time which could have
been devoted to really solving
problems in health care. There has
been no real combined effort by state
government to involve consumers and
health care providers in legislation that
is drafted. Yes, consumers and health
care providers have been able to voice
their opinions to some extent on
issues, but they have not been
specifically asked to help develop
health care legislation.

Where do we go from here? First,
we must answer questions that can be
answered.

Do we need to spend our health
care dollars more efficiently and make
the system more cost effective? YES.

Do we need to find ways to provide
coverage to those who may be able to
afford it if the costs were lower? YES.

Do we need to find ways to provide
care to those who cannot possibly
afford it? YES.

Do we need to find ways to make
people more responsible for
preventing illness? YES.

Do we need legislation to
accomplish this? MAYBE NOT.

Do we need a major overhaul of the
state’s entire health care system? NO.

It’s time that consumers, health care
providers and government leaders
leave their baggage at the door and
come together to develop some real
solutions. Can we put together a
group that would be able to achieve
this goal without legislation? I think
this will be the answer. As physicians,
we must be willing to be a part of the
solution.

James L. Comerci, M.D.

1 10 THE WEST VIRGINIA MEDICAL JOURNAL

Editorial

Saving big dollars

Well, all right then, let’s talk about
dollars. Everyone, including doctors, is
agreed that medical care costs too
much.

The problem is really not access.
There are no pandemics, no bodies
lying about in the streets. There is no
one who will challenge the fact that
the quality and technological
sophistication of health care in this
country are unmatched anywhere on
this planet.

Medical care just costs too much —
so much that other things in the
household budget like vacations,
dining out, entertainment of various
sorts, stylish clothing and new cars are
being squeezed out. This list could be
extended in any number of specific
and non-specific directions, none of
them inherently bad.

Since the problem is indeed scarce
dollars rather than limited access,
discriminatory insurance or a
dysfunctional organizational setup,
let’s look at how we might conserve
dollars without damaging quality.
Hillary attempts saving money via a
very poorly disguised system of
rationing. She and her health care
guru, Magaziner, lop off a hundred
million here and a few billion there.
They fancifully project systemic and
attitudinal conversions among the 80%
or more of the consumers presently
satisfied with their care, and with
straight faces proclaim that all the
figures balance out and everyone will
now be able to snuggle down, happy
in their new found security.

A recent piece in the New York
Times suggests that administrative
costs presently account for more than
40% of total medical care costs. This is
a startling figure, but when one
considers the number of employees
found in administrative offices of any
hospital; the non-medical workers
filling out insurance forms and other
required records in the ordinary
doctor’s office; insurance company
employees examining materials
generated at doctors’ offices and

hospitals and then filling out more
forms and papers; the battalions of
health care managers busily churning
out forms and phone calls; the
controllers, regulators and rule makers
sitting in their government offices
doing whatever they do to fill their
day; it begins to seem possible that at
least 40% of medical care costs can be
attributed to other than doctors and
nurses who, at the very least, are
terribly outnumbered by these others.

Of course, Hillary promises to do
away with a lot of the paperwork we
refer to. She proposes to do this by
creating a bureaucracy on a scale
previously unheard of and perhaps
even undreamed of for our or any
other government, including that of
the Soviet Union which attempted to
manage and control just about
everything. Her plan will certainly
eliminate much of present day medical
paperwork, but what she does not
mention is that her plan will simply
replace that with an even greater
burden of new and different paperwork.

With total costs for medical care in
the United States approaching $1 trillion
yearly, 40% amounts to roughly $400
billion, which presents a rather fat
target for anyone honestly interested
in saving dollars. At any rate, that
route seems a far more humane
approach to economy than denying
bypass surgery to those beyond 70
years old, dialysis to those over 55,
joint replacements to those over 75, or
any number of other similarly
excellent cost savers.

As fine a target for cost cutting as
administrative costs appear to be,
there are realistically certain limits that
can be expected in the pursuit of
economy in that direction. Economies
available in administrative costs pale,
however, in comparison to those
available via tort reform and the
subsequent effect of that reform on
defensive medicine.

In overall medical care costs,
professional liability premiums paid by
doctors seem perhaps insignificant --

probably $6 billion to $7 billion out of
nearly a $1 trillion medical care figure.
To keep themselves out of the hands
of rapacious and predatory plaintiff
lawyers, however, most doctors,
probably all doctors, are willing to go
the extra mile in being careful. They
want to be sure. Doctors know this
costs a lot of money but they like to
sleep at night. Then too, they have a
high regard for their reputations.

They dislike spending hours, days,
even weeks giving depositions or
court testimony. It makes doctors
nervous to be harassed by the likes of
lawyers. It makes doctors angry to
endure the insults of, or even the
presence of lawyers.

To the extent doctors can be
reassured, sleep at night and feel
relatively protected from the circling
pack of slavering legal wolves, it costs
patients and their insurers a substantial
amount of money. The least amount
of money attributed to defensive
medicine costs is $30 billion. The high
estimate is 10 times that, about one
third of total medical care costs, a figure
in the neighborhood of $300 billion.

If we were to take the advice of one
Shakespearean character — “First, kill
all the lawyers” -- we might be able to
save 100% of that amount. Short of
that drastic but in some ways
attractive step, we can save some very
significant part of the defensive
medicine cost figure.

Now, we are talking about some
real money and we haven’t yet
mentioned product liability suits by
the same legal parasites and the effect
of these on the cost of drugs.

Yes, medical care costs can be
brought down dramatically, and we
can accomplish this without rationing
and without affecting the quality of
medical care. If it is done right, the
only unhappy group remaining will be
plaintiff attorneys. That seems like an
acceptable price to pay. Nobody likes
them anyhow.

- Stephen D. Ward, M.D.

Editor

MARCH 1994, VOL. 90 111

In My Opinion

The new physicians — kill or cure?

The activities of Dr. Jack Kevorkian
and recent referendums proposing
euthanasia in the states of Washington
and California that were only narrowly
defeated, suggest that the role of
physicians in the United States may be
changing from merely treating diseases
to a more active one.

Since pre-Christian times, the
Hippocratic Oath has made a sharp
distinction between the physician as a
healer and as a killer. A 1988 article in
JAMA powerfully stated that a
physician cannot be both (1). At
times, physicians have played a dual
role — most notoriously in Hitler’s
Germany.

In spite of the very low, and
perhaps vanishingly rare incidence of
truly intractable pain (2), physicians
are becoming more involved in
suicide and euthanasia, as well as in
such activities as the legal executions
of criminals (3). In an alleged era of
limited resources, society may indeed
need to examine the cost of preserving
life. It likewise needs to examine the
cost of failing to preserve life.

Oregon has recently proposed to
limit the care available to certain
categories of patients, acknowledging
the fact that, as a direct result, some
patients will die. Limits can now be
placed on the actual length of a
person’s life to prevent “needless”
expenses during the process of dying.
Society might even come to

recognize that transplantation
medicine would greatly benefit from a
reliably available supply of organs
from elderly patients or executed
criminals. Society would then have a
great need for doctors willing to
expedite killings or executions. In the
future, society might further
demonstrate its need for such doctors
by mandating limits on the number or
types of children allowed to live,
easily extending this to infanticide like
China’s brutal population control
program (4).

In anticipation of these or similar
happenstances, I propose the creation
of the position of Doctor of
Necrotology or N.D. The N.D. would
be by statute our society’s only legal
killer of innocent human life. The sole
mandatory requirement for the
position of N.D., other than sufficient
intelligence to utilize the “tools of the
trade,” would be compassion — either
for suffering patients or for the
members of society as a whole.

Indeed, possession of the virtue of
compassion to the greatest possible
degree will be absolutely essential for
the successful performance of the
N.D.’s duties. In no other way could
we successfully overcome strongly
built-in Western cultural and ethical
aversions to the killing of an innocent
person. It is obvious that careful legal
limits would have to be established
for doctors in this specialty. The

historical record shows how easily the
role of licensed killer can be
corrupted or perverted.

Physicians currently assisting in the
judicial execution of prisoners or
performing elective abortions, of
course, would be grandfathered the
N.D. degree. With the passage of
appropriate laws, the roles and
numbers of these specialists would
grow. N.D.s would perhaps find it
difficult to fit comfortably into
conventional medical societies.
However, because of their dual
medico-legal sanction, they would
easily find compatible brotherhood as
a component society of the American
Bar Association.

The final result is that the clear
dichotomy between Doctors of
Healing and Doctors of Death would
be re-established, and medicine could
regain its soul.

Robert C. Belding, M.D.

Beckley

References

1 Gaylin W, Kass LR, Pellegrino ED, Siegler M.
Doctors must not kill. JAMA. 1988;259:2139-40.

2. Truog RD, Berde CB. Pain, euthanasia and
anesthesiologists. Anesth 1993;78:353-60.

3. Truog RD, Brennan TA. Sounding Board -
Participation of physicians in capital
punishment. N Engl J Med 1993;329:1346-50.

4. Mosher SW. A mother's ordeal: one woman’s
fight against China's one-child policy. New
York: Harcourt Brace & Co., 1993-

1 1 2 THE WEST VIRGINIA MEDICAL JOURNAL

Special Correspondence

Dear Dr. Ward:

Greetings from Scottsdale. I wrote the following satire today and thought you might want to publish it in
the West Virginia Medical Journal.

Two months ago I paid for my last haircut at Tony’s. It cost $8 plus a $2 tip. Now, I have an insurance
policy with a preferred barber organization (PBO). For $100 a year I can have all the haircuts I need, but of
course, I must go to a participating barber shop.

Yesterday, I selected Sam at Preferred Barbers of America (PBA). They are a participating provider. Sam
had a few' suggestions. He said I’d look a lot better if I had my hair cut once a month (instead of every other
month) and it would be covered by my policy providing I had a second opinion form completed. This form
could be provided by any participating barber shop other than PBA. Sam suggested Family Barbers of
America (FBA) since they often provide second opinion forms for each others customers.

Sam also said that I would look spiffier if I got a style cut. He explained that even though a style cut would
cost $5 more than the standard $10 haircut, I would only be responsible for half ($2.50) and they would be
glad to bill me for it. In addition, he said after I had met $20 of co-pays per year, there would be no more
charges to me.

Well, I wasn’t thrilled with Sam’s haircut.

Why, I asked, didn't he shave around the ears and trim my nose and eyebrow's like Tony always did. Sam
explained that those were not covered benefits under the basic plan. The premium for the deluxe haircut
plan was $150 per year.

At my insistance, Sam had his secretary show me the bill that his billing clerk would be submitting for my
haircut.

Basic haircut

$10.00

Style

2.50 ($5.00 x 50%)

Wash

1.00

Drape

1.00

Gratuity (15%)

2.18

Billing fee

2.00

Total

$18.68

I asked Sam how my PBO could afford to provide these services for $100 per year. Sam explained that
they really cannot, but they were losing money in an attempt to capture the market share and that the
premiums would be going up 30% next year.

I went back to Tony and asked why he did not participate as a provider for my PBO. Tony explained that
he would have to invest $30,000 in a computer for billing the PBO electronically and he’d have to hire
another employee to do the billing. He decided instead to stick it out for one more year and retire early.

Harold L. Saferstein, M.D.

Editor’s Note: Dr. SaJ'erstein retired from bis dennatolog}’ practice in Wheeling , W. Va. at age 59 and now
lives in Scottsdale, Ariz.

MARCH 1994, VOL. 90 113

AMA president to deliver address at Annual Meeting

Robert E. McAfee, M.D., who will
become president of the AMA in June,
will discuss political issues affecting the
practice of medicine when he speaks
at 9 a.m. on August 20 during the
Second Session of the WVSMA’s 127th
Annual Meeting at The Greenbrier in
White Sulphur Springs.

A surgeon practicing in South
Portland, Maine, Dr. McAfee has been
serving as president-elect of the AMA
since June 1993- Prior to this, Dr.
McAfee served as vice chair of the
AMA Board of Trustees from 1990-92;
as a member of the Executive
Committee of the board from 1988-92;
and as an AMA commissioner to the
Joint Commission on Accreditation of
Healthcare Organizations from 1986-93.
In addition, he also served as president
of the AMA Education and Research
Foundation from 1986-88, and as its
secretary-treasurer from 1985-86.

Before his election to the AMA
Board of Trustees in June 1984, Dr.
McAfee was a delegate to the AMA
House of Delegates from 1974-84, and
chair of the New England Delegation
from 1976-84. A past president of both
the Cumberland County Medical
Society and the Maine Medical
Association, Dr. McAfee is also a past
member of the Board of Directors of
the Maine Health Systems Agency, the

For the first time in 50 years, the
FDA is proposing to fortify the nation’s
food supply for the good of public
health. The proposal calls for adding
the B vitamin folic acid to flour due to
mounting evidence that folic acid, taken
early in pregnancy, can prevent birth
defects of the spine and brain (neural
tube defects), such as spina bifida.

The FDA recently announced that
manufacturers of vitamin supplements
containing folic acid may rightfully
claim its benefits. Approximately 2,500
babies are born with neural tube
defects each year in this country; 500
die as a result. An estimated 50% of
these defects could be prevented with

McAfee

Project Review Committee (Certificate
of Need) and the Board of Directors of
Maine Blue Cross and Blue Shield.

A native of Portland, Dr. McAfee
received his M.D. degree from Tufts
University School of Medicine in I960.
He completed his residency in general
surgery at Maine Medical Center in
1965, where he served his internship.
An attending surgeon at Maine Medical
Center and chief of vascular surgery at
Mercy Hospital in Portland, Dr. McAfee
is also currently an associate professor
of surgery at the University of Vermont.

adequate folic acid intake at the
appropriate time during pregnancy.

Folic acid occurs naturally in foods
such as leafy, green vegetables, some
cereals and legumes, but, for many, it
may be difficult to consume an
adequate amount through a normal
diet. Adding folic acid to the flour
supply would help to ensure that more
pregnant women get the folic acid
they need. If the proposal is finalized
this year, it would still be months
before it would be implemented. Even
then, some pregnant women may not
consume enough flour products to get
the recommended amount of folic acid.

To ensure adequate intake and

Dr. McAfee is on the Executive
Committee and is a past president of
the Anerican Cancer Society, Maine
Division, and also serves on the
American Cancer Society’s National
Board of Directors. In 1981, he
received the American Cancer Society’s
Frederick G. Payne Memorial Award,
and in 1986 was presented with the
National Bronze Award, the highest
award given to a volunteer of the
Anerican Cancer Society.

A member of the Medical Advisory
Board for Community Health Services
in Portland, Dr. McAee is the first
recipient of the O’Wril Award for
Community Service in Communication
from the Gannett Broadcasting
Company in Portland. He is also the
1985 recipient of the Huddilston Medal
of the Maine Lung Association and the
1989 Governor’s Medal from the
Emergency Medical Services Board for
his contributions to the health care of
the people of Maine.

Information concerning other
speakers at this year’s WVSMA Annual
Meeting will be published in upcoming
issues of the Journal. A registration
form for the meeting appears on page
95 and additional details can be
obtained by phoning Nancie Diwens
at (304) 925-0342.

prevent birth defects

thereby reduce the risk of neural tube
defects, many physicians and groups
such as the March of Dimes suggest
that women who might possibly
become pregnant eat a balanced diet
and take a prenatal multivitamin/
multimineral supplement containing
folic acid every day. To educate the
public and health care professionals
about the importance of folic acid, the
March of Dimes and Wyeth-Ayerst
Laboratories are conducting a national
campaign.

To obtain informational materials
about this subject, contact the West
Virginia Chapter of the March of
Dimes at (304) 722-4255.

FDA proposing to add folic acid to flour to help

1 14 THE WEST VIRGINIA MEDICAL JOURNAL

Dr. Carr named head
physician of Summer
Olympic Festival

Dr. Daniel Carr,
an orthopedic
surgeon at Scott
Orthopedic
Center, Inc. in
Huntington, has
been selected to
be the head
physician at the
1994 Summer
Olympic Festival
in St. Louis. His
duties will include
supervising all medical personnel and
overseeing the treatment of all
athletes.

Dr. Carr received his medical
degree from the University of
Vermont in 1980. He interned at the
University of Utah from 1980-81 and
then did a residency at the University
of Vermont from 1981-85. Dr. Carr
has been a member of the WVSMA
and the Cabell County Medical
Society since 1985.

Fifth Annual Rush
Symposium set for
Saturday, May 21

“Leflunomide: A New Direction in
Immunosuppression" will be the topic
of the Fifth Annual Rush Symposium
on Transplantation, which is
scheduled for Saturday, May 21 at
Rush-Presbyterian-St. Luke’s Medical
Center in Chicago.

The rapidly advancing technology
in anti-rejection therapy has lead to a
new and promising direction in
immunosuppressive drugs, specifically
the novel drug Leflunomide.
Leflunomide has many promising
properties including its ability' to
prevent and reverse allograft
rejection, to down-regulate
alloantibody production and to
provide exceptional control of
concordant xeno rejection, placing it
high among the small group of
evolving drugs with potential for
clinical transplantation. The
symposium will feature a series of
lectures describing Leflunomide ’s
action in rodents and in dogs, its
mechanism of action and its early
expanse in human use.

For symposium details, call the
Transplant Program Physician Relations
Coordinator at (312) 942-6242.

Spirometry training
course offered by ALA

The American Lung Association of
West Virginia is once again offering
its course in “Spirometry Training in
Occupational Health" at John XXIII
Pastoral Center in Charleston on April
27 and 28.

This course is designed for nurses,
physicians, respiratory therapists and
other health care providers involved
in spirometry screening programs. It
will focus on the use of screening
spirometry for the evaluation of lung
function in occupational health and
other health care facilities. Lectures,
small group sessions and hands-on
experience ensure that each participant
will meet the course objectives.

Karen B. Mulloy, D.O., M.S.C.H., is
the spirometry course director. Dr.
Mulloy is chief of the Division of
Occupational and Environmental
Health in the Department of Family
and Community Health at the MU
School of Medicine. Lecturers include
Bipin H. Avashia, M.D., clinical
associate professor of medicine at the
WVU School of Medicine, Charleston
Division; and John L. Hankinson,
Ph.D., chief of the Clinical
Investigations Branch of the Division
of Respiratory Disease at the
Appalachian Laboratory for
Occupational Safety and Health.

The National Institute for
Occupational Safety and Health
(NIOSH) has given this training
session Course Approval #026, and
St. Francis Hospital has approved tit
16 CME contact hours.

There is a discount fee for
registrations received by April 1 and
for companies sending three or more
employees. Enrollment is limited, so
early registration is recommended.

For more information, call Shawn
Harris Chillag at (304) 342-6600 or
1-800-LUNG-USA in WV.

Logan County Medical
Alliance to host dinner
for Doctor’s Day

In honor of Doctor’s Day, members
of the Logan County Medical Alliance
are hosting a dinner for physicians,
auxilians and their families on March
30 at 6:30 p.m. in the Logan General
Hospital Cafeteria. CME will be offered.

To RSVP, phone Siromani Bellam
at 583-9353 or Trudy Tordilla at
583-6272.

Fifteenth Cape Cod
Institute scheduled

The Fifteenth Annual Cape Cod
Institute, sponsored by the
Department of Psychiatry at the Albert
Einstein College of Medicine, will
consist of a summer-long series of
postgraduate courses for professionals
in mental health, health science, and
applied behavioral science. Topics
include psychodynamic therapy,
behavioral medicine, brief therapy,
humanistic psychology, psychological
assessment, neuropsychology, family
therapy, childhood and adolescence,
and organizational development.

Sessions will be held weekday
mornings June 27-September 2, from
9 a.m. until 12:15 p.m., leaving the
afternoons free for leisure and study.
Optional discussion groups and social
gatherings are arranged, and Institute
staff members provide abundant
information about activities on Cape
Cod.

A complete course catalogue may
be obtained front: Cape Cod Institute,
Albert Einstein College of Medicine,
1308A Belfer Building, Bronx, NY,
10461; (718) 430-2307.

Ninth Medicolegal
Investigation of Death
Seminar planned

The Ninth Medicolegal Investigation
of Death Seminar is set for April 9 at
the Robert C. Byrd Health Sciences
Center of West Virginia University in
Morgantown.

This seminar is sponsored by the
Office of the Chief Medical Examiner
of the North Central Region; the State
of West Virginia; the West Virginia
Deputy Sheriffs Association; the West
Virginia State Lodge Fraternal Order
of Police, the West Virginia Chiefs of
Police Association, the West Virginia
Troopers Association and the
Department of Pathology at the West
Virginia University School of
Medicine.

For more details, phone Donna
Golleher at (304) 293-5569.

SEHTBEXI1

Everybody’s Wearing Them

AMERICAN LUNG ASSOCIATION.

1-800-LDNG-QSA

MARCH 1994, VOL. 90 115

PHYSICIAN’S RECOGNITION AWARDS

We wish to congratulate the following WVSMA members who recently received
Physician’s Recognition Awards from the AMA for voluntarily completing 150 credit
hours of continuing medical education during the past three years:

Brooke

Patsy P. Cipoletti, MD

Cabell

James R. Morris, MD
Jose I. Ricard, MD
Jack R. Steel, MD
Gerald E. Vanston, MD
Deleno H. Webb, MD

Central

Stephen R. Cirelli, MD
Moosa Kasmet, MD
Dwight A. Wagenknecht, MD

Eastern Panhandle

Ray Lewis, MD
Joseph G. McCabe, MD
Edward L. Pinney, MD

Favette

Arsenio P. Navarro, MD

Greenbrier

Steven B. Hefter, MD
Ronald R. Scobbo, MD

Harrison

Paul M. Brager, MD
John J. Crossen, MD
Chinmay K. Datta, MD
David R. Hess, MD
Catalino B. Mendoza, MD
Louis C. Palmer, MD

Kanawha

David Abramowitz, MD
Adla Adi, MD
Ronald E. Cordell, MD
Thomas O. Dickey, MD
Ravindra K. Gogineni, MD
Echols A. Hansbarger, MD
Albert F. Heck, MD
Alberto C. Lee, MD
William C. Morgan, MD
Elizabeth L. Spangler, MD
Martin S. Wershba, MD

Marion

Stephen Chor Kin Lau, MD

Marshall

Kenneth J. Allen, MD

Mercer

Clifford H. Carlson, MD
Felipe T. Pia, MD

Monongalia

Glen F. Aukerman, MD
Donald E. McDowell, MD
Vadrevu K. Raju, MD
Sydney S. Schochet, MD
Raymond A. Smego, MD
Robert L. Smith, MD
Jeffrey A. Stead, MD
Harry L. Taylor, MD
Richard M. Vaglienti, MD
Stephen J. Wetmore, MD

Ohio

George E. Bontos, MD
Edwin E. Cohen, MD
Paul R. Hedges, MD
Krishna R. Urval, MD
Jeffrey M. Yost, MD

Parkersburg Academy

Robert M. Biddle, MD
E. Samuel Guy, MD

Putnam

Alfonso P. Cinco, MD

Raleigh

Sung W. Chang, MD
William A. Scaring, MD
Syed A. Zahir, MD

Tvgart’s Valiev

Fouad H. Abdalla, MD

116 THE WEST VIRGINIA MEDICAL JOURNAL

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Marshall University School
of Medicine - Huntington

March 21

“Polyreactive Antibody Molecules and
Natural Immunity” (Research Day
Opening Lecture), Abner Louis
Notkins, M.D., 7 p.m., Marshall
University Fine Arts Building

March 22

“7th Annual Research Day,” 8 a.m.,
Holiday Inn Gateway-Convention
Center, Barboursville

Raleigh County Medical Society -
Beckley

March 22

“Update on Use of Anti-Inflammatory'
Drugs,” Howard Feinberg, D.O.,

6:30 p.m.. Black Knight Country Club

March 24

“New Approaches to Community-
Acquired Respiratory Infections,”
Samuel Pegram, M.D., 6:30 p.m.,
Black Knight Country Club

March 29

“Bedwetting,” William F. Tarry, M.D.,
6:30 p.m., Raleigh General Hospital

Robert C Byrd Health Sciences
Center of WVU - Charleston

March 24-25

“21st Annual Newborn Day:

Metabolic Disorders of the Newborn”

April 7

“Obstetrical Update” (co-sponsored
by the West Virginia Chapter of the
.American Academy of Family
Physicians and CAMC), Huntington

April 7

(Teleconference) “Pregnancy-Induced
Hypertension," Todd C. Resley, M.D.

April 19

“Mini and Maxi Flaps” (sponsored by
The Eye and Ear Clinic of Charleston
and the Dept, of Surgery), Ted Jackson,
M.D., 4th Floor Faculty Lounge

April 21

(Teleconference) “Childbirth
Education Update," Paula Vasale,
R.N.C., B.S.N., C.E.S.

May 5

(Teleconference) “Respiratory
Distress in the Newborn," Stefan R.
Maxwell, M.D.

May 19

(Teleconference) “Blood Borne
Pathogens: The Health Care Providers’
Risk," Elizabeth A. Funk, M.D.

May 11-12

“3rd Annual Issues in Perinatal
Health Care”

May 17

“Management of a Congenital Neck
Mass” (sponsored by The Eye and
Ear Clinic of Charleston and the
Dept, of Surgery), R. Austin Wallace,
M.D., F.A.C.S.

Robert C Byrd Health Sciences
Center of WVU - Morgantown

March 24-25

“WVU Urology Update" (sponsored
by the WVU Dept, of Urology and
the West Virginia Urological Society)

March 26-27

“Spring Meeting of the West Virginia
Chapter of the American Academy of
Pediatrics” (sponsored by the
WVAAP and the WVU Dept, of
Pediatrics), Morgantown

April 9

“9th Medicolegal Investigation of
Death Seminar” (co-sponsored by
the Office of the Chief Medical
Examiner)

April 13-15

“Awareness to Action II” (co-sponsored
by West Virginians for Fetal Alcohol
Syndrome Action), Days Inn,
Flatwoods

April 14-16

“Southern Group on Educational
Affairs Spring Regional Meeting”
(co-sponsored by the WVU School of
Medicine, MU School of Medicine
and the State of West Virginia),
Marriott Hotel, Charleston

April 22-24

“West Virginia State Radiological
Society Spring Meeting: Breast Care
Update 1994 (sponsored by the
9CWU Dept, of Radiology and the

West Virginia State Radiological
Society), Lakeview Resort and
Conference Center, Morgantown

April 30

“Current Concepts in Cancer Care for
the Non-Oncologist” (co-sponsored
with Monongalia General Hospital),
Lakeview Resort and Conference
Center, Morgantown

May 1-4

“Wellness Conference,” Lakeview
Resort and Conference Center,
Morgantown

May 20

“Second Annual Stephen C. Rector
Visiting Lectureship in Emergency
Medicine” (sponsored by the WVU
Dept, of Emergency Medicine)

West Virginia State Medical
Association - Charleston

March 26

Marbury vs. Madison Loss Prevention
Program - Wheeling

April 14

Office Personnel Workshop -
Parkersburg

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Gassaway □ Braxton County Memorial
Hospital, March 23, 6:30 p.m.,
“Oncology Emergencies,” Steven
Jubelirer, M.D.

Oak Hill □ Plateau Medical Center,
March 22, 6:30 p.m., “New Treatment
for Fibrillation/Flutter,” Ronald J.
McCowan, M.D.

Parkersburg ★ Camden-Clark Memorial
Hospital, March 23, 7 a.m., “Some
New or Rediscovered Bacterial
Pathogens”

★ Camden-Clark Memorial Hospital,
March 30, 7 a.m., “The Impaired
Professional”

Point Pleasant □ Pleasant Valley
Hospital, March 24, noon, TBA

MARCH 1994, VOL 90 117

■eeS Poetry Corner V

March

24-25-West Virginia Urological Society’s
Annual Spring Meeting, Morgantown

April

5-9-20th Annual Meeting of the Society for
Biomaterials, Boston
8-9-Psychiatry Clinical Update: The
Treatment Resistant Patient: Thick Chart
Syndrome (sponsored by Ohio State
University), Columbus
8-10-American Society for Contemporary
Medicine and Surgery, Orlando, Fla.
8-10-42nd Annual Scientific Assembly of the
West Virginia Chapter of the American
Academy of Family Physicians, Huntington.
10- 11-Planning Conference on Management
Requirements for a National Implant Data
System (sponsored by the Society for
Biomaterials), Hyannis, Mass.
15-l6-Gastroenterology Update: 1994
(sponsored by Ohio State University),
Columbus

16 -22-American Occupational Health
Conference (sponsored by the American
College of Occupational and Environmental
Medicine), Chicago

21-24-American College of Physicians,
Miami

21-24-47th Annual National Spring Meeting
of the West Virginia Academy of
Ophthalmology, White Sulphur Springs

28- 30-Federation of State Medical Boards
Annual Meeting, Washington, D.C.

29- 30-Hypertension and the Kidney
(sponsored by Ohio State University),
Columbus

May

12- 13-Building Blocks of Health Care
Reform: Health Information and Quality
Assessment (sponsored by AMPRA,
Consumer Coalition, NAHDO and NBCH),
Washington, D C.

13- 14-Topics in Radiology (sponsored by
the University of Pittsburgh School of
Medicine), Pittsburgh
13-15-Rheumatology and Allergy Update:
1994 (sponsored by Ohio State University),
Mt. Sterling, Ohio

13-15-The Managed Care Revolution:
Winning Strategies for Internists (sponsored
by the American Society of Internal
Medicine), Boston

18-20— 47th Annual National Conference of
the President's Committee on Employment
of People With Disabilities, Atlanta

For More Information . . .

Contact the Journal at (304) 925-0342.

Snowy Vandalia

A light snow spread upon the ground
A lacy tablecloth laid down
With here and there the edge turned up
From frosted hill and dell and cup.

And there were clouds that rode the breeze
On silent scenes, where a twig or sneeze
Could snap and break the reverie
Marching time on snow topography.

Fuzzy fingers of snow outlined the branches
Like caribou antlers in rhythmic dances
For men by the fire; or, they’re now “chandelier crystals"

To ladies, while the wind trails like minstrels.

Orbital gyrations of an atomic clock or star
Weighed out time to heal so far.

(Was there ever time to think and feel?)
I wouldn 't doubt, where snow plopped in free fall,

(Breaking the crust beneath his heel)
That Bigfoot walked the Hills, at all.

Lee L. Neilan, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward, M.D.,
Editor, West Virginia Medical Journal P. O. Box 4106, Charleston, WV 25364.

wi just 9/ants me to make him feel good eNou&b

to <3>E"T BACK To 1>0IN& THE THIN&5 THAT AMDf

HlMFEEl no THE FIRST ?1ACE . "

1 18 THE WEST VIRGINIA MEDICAL JOURNAL

o o

Physician

FOLLOW THROUGH

It’s the professional edge
in patient satisfaction and
medicine compliance.

Mail to:

NCPIE

666 Eleventh Street, NW
Suite 810

Washington, DC 20001

Prescribing the right medicine
isn't enough. It’s important to
follow through and explain
how and when to take it,
precautions and side effects.

The National Council on
Patient Information and
Education (NCPIE) has free
materials to help you talk
about prescriptions.

Yes! Please send me free information on patient
medicine counseling. (Please Print)

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

State's vital statistics
released for 1992

The 1992 West Virginia Vital
Statistics has been released by the
Bureau's Office of Epidemiology and
Health Promotion. This report is
compiled annually to detail births,
deaths, marriages and divorces
occurring among state residents.

The number of births in 1992 was
22,156, down from 22,509 in 1991.
More than 27% of all births were to
unwed mothers. Although the number
of births to teenagers dropped to 3,809
in 1991, the percentage of births to
unmarried teens increased from 55% in
1991 to 56.6% in 1992.

The percentage of low birthweight
babies, those weighing less than 5
pounds, increased to 7.2% in 1992, up
from 6.8% in 1991. Of all births in 1992,
26% were Cesarean section deliveries,
and 77% of women giving birth in 1992
reported they received prenatal care
during their first trimester of pregnancy,
while nearly 27% smoked and 1 .6%
used alcohol during pregnancy.

The number of state deaths
decreased in 1992 to 19,696, down
from 19,951 in 1991 This established
a death rate of 10.9 deaths per 1,000
people, and the average age of death
was 68 years for men and 75 years for
women.

For a copy of the report or for more
information, contact the Health
Statistics Center at (304) 558-9100.

Progress achieved in
reaching health goals

A series of reports will monitor the
state’s efforts in accomplishing the
goals in 21 health priority areas
described in West Virginia Healthy
People 2000 , a report published in
1991 by the Bureau which lists
specific objectives for the year 2000.

West Virginia Healthy People 2000
Updates look at disease trends and

health behaviors, and predict the
status of health conditions in 2000.
The updates also identify policy
initiatives implemented to meet goals.
Ten of the 21 updates have been
completed, addressing unintentional
injuries, AIDS/HIV infection, tobacco
use, physical activity, immunization
and infectious diseases, heart disease
and stroke, sexually transmitted
diseases, diabetes, educational
programs, and nutrition.

The goal of increasing the number
of women who breastfeed has already
been met, and if present trends
continue, goals will be met to reduce
death from fires and burns among
preschoolers, reduce deaths due to
heart disease, confine the prevalence
of HIV infection, and limit the cases of
gonorrhea. Headway is also being
made in reducing deaths from falls
among the elderly, lessening cigarette
and smokeless tobacco use, increasing
immunization levels, implementing
programs to increase the detection,
treatment and management of diabetes
and its complications, reducing death
from strokes, establishing projects to
increase daily consumption of fruits
and vegetables, and reducing the
prevalence of hypertension.

Unfortunately, increases are being
seen in the rates of motor vehicle
deaths among children, the number of
diagnosed AIDS cases, syphilis rates,
and the prevalence of sedentary
lifestyle and of obesity. To change
these trends, 32 community health
promotion sites have been established,
10 counties are participating in healthy
schools projects, and several public
and private worksite wellness programs
have been implemented.

Future updates will address alcohol
and other drugs, family planning,
mental health, violent and abusive
behavior, occupational safety and
health, environmental safety and
health, food and drug safety, oral
health, maternal and child health,
cancer, clinical preventive services,
and data systems. When all the
updates are compiled, objectives will
be reviewed and adjusted as needed.

For a copy of the updates or for
more details, contact the Healthy
People 2000 Project Director Tom
Sims at (304) 558-0644.

Surveyors complete
qualifications test

The Bureau's Office of Health Facility
Licensure and Certification (OHFLAC)
reports that all its employees who
survey long-term care (LTC) facilities
have successfully completed the
Surveyor Minimum Qualifications Test
(SMQT). The OHFLAC now has 31
individuals who have passed the test,
and West Virginia is one of only 16
states nationwide in which all
surveyors have successfully completed
the SMQT.

The OHFLAC is the office within the
Bureau of Public Health responsible
for licensure and certification
compliance surveys in accordance with
state and federal regulations. LTC
certification qualifies eligible
beneficiaries to receive services funded
by Medicare and Medicaid.

In 1987, Congress enacted an
extensive reform of LTC affecting the
provision of nursing home services as
part of the Omnibus Budget
Reconciliation Act (OBRA 87). Among
the mandates outlined in this rule was
the requirement for all LTC surveyors
to meet minimum qualifications. The
Health Care Financing Administration
(HCFA) responded to this mandate by
developing the SMQT. Successful
completion of the training and testing
program identifies individuals who
possess the minimum knowledge,
skills and abilities necessary for LTC
facility surveys, integral components
of surveyors’ on-the-job performance.

The test is comprised of two
modules. Module A is designed for all
LTC surveyors and tests their ability to
evaluate residents’ rights and the
environment in which the nursing
home resident lives. Module B is
designed for those who perform
reviews related to quality of care,
testing their clinical judgement
relative to nutrition, medication,
resident assessments and nursing
care.

As of February 1, no individual may
conduct an independent survey of a
LTC care facility unless the necessary
modules have been successfully
completed.

120 THE WEST VIRGINIA MEDICAL JOURNAL

'The President Series - Symbolizing Quality and c. Excellence

Crafted from select walnut veneers and hand-rubbed
finishes, ‘The President Series mirrors the excellence of
the leaders it serves.

Subtle details make ‘‘The ‘T resident Senes the reference in
traditional design. Burl Walnut or hand-tooled leather-
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of the series.

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Phone: 343-0103 or 800-734-2045

Our Name Says It All...

turn-key adj (1927): built, supplied, or installed complete and ready to operate

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Robert C. Byrd
health Sciences Center

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C Byrd Health Sciences Center of West Virginia
University , CommunicationsDivision, Morgantown

First neuroradiology
consult airs on MDTV

The first Mountaineer Doctor
Television (MDTV) neuroradiology
consult was conducted in December
by Dr. Jeffery P. Hogg, who assisted
an emergency room physician at Davis
Memorial Hospital in Elkins.

“Although the ER physician had
some exposure to radiological
imaging, he wanted to base his
treatment and diagnosis decisions on
sharing the films and the patient’s
mode of presentation with someone
who had a greater depth and breadth
of training in neuroradiology,” says
Dr. Hogg, associate professor of
radiology/neurology. “By using the
MDTV system, the doctor didn’t have
to mail the film of the CT scan and
have a two or three day delay. The
patient was there, the films were
there, and, through MDTV, I was there
looking at the films on the viewbox.”

MDTV allows physicians in outlying
areas of the state to consult with
specialists at the Robert C. Byrd Health
Sciences Center.

Khakoo receives
ACP’s Laureate Award

Dr. Rashida A.
Khakoo, professor
and interim chair of
the Department of
Medicine, has
received a Laureate
Award from the
West Virginia
Chapter of the
American College of
Physicians (ACP).
Laureate Awards
are presented to fellows of the ACP
who demonstrate a commitment to
excellence in medical care, education
or research, and in service to their
communities and ACP. Dr. Khakoo was
given this honor at the ACP's Annual
Scientific Meeting in Morgantown.

Smith appointed to
national task force

emergency
medicine, has been
appointed to serve
as the only doctor
on the national
Tort Refonn Task
Force.

The task force is
charged with reviewing the tort
reform provisions of the National
Llealth Security Act and relaying
recommendations to the White
House and Congress.

Lee B. Smith,
M.D., J.D., a clinical
instructor of

Neurology faculty
serve as examiners

Several Department of Neurology
faculty members served as examiners
at the Part II Oral Examination of the
American Board of Psychiatry and
Neurology, which was conducted
January 9-11 in Baltimore, Md.

The faculty participating were Dr.
Ludwig Gutmann, professor and chair;
Dr. Jim Martin, professor; Dr. John
Bodensteiner, professor and section
chief of pediatric neurology; Dr. Alvaro
Gutierrez, assistant professor and
director of the Neurophysiology Lab;
Dr. Bob Keefover, associate professor
and director of the Neuropsychiatry
Program; and Dr. Laurie Gutmann,
assistant professor and medical
director of the EMG Lab.

Timberlake, Stewart
earn national honors

Smego speaks at
international meeting

Raymond A.
Smego Jr., M.D.,
M.P.H., associate
professor of
infectious diseases,
and director of the
International
Health Program,
was a speaker and
symposium leader
at the 15th
International Conference on Medical
Education for the Christian Medical
and Dental Society in Kenya.

Dr. Smego's topics included
multidrug-resistant tuberculosis, global
antimicrobial drug resistance patterns,
national HIV/ AIDS control and
management strategies, essentials of a
third-world hospital formulary, and
WHO-targeted disease eradication.

Interim director of
trauma center named

Dr. Laurel Omert has been named
interim director of the Jon Michael
Moore Trauma Center. Dr. Omert is
assistant professor of trauma in the
Department of Surgery.

“The Department of Surgery and the
trauma center are most fortunate to
have the services of a surgeon of Dr.
Omert’s caliber and background," Dr.
Gordon F. Murray, professor and chair
of surgery said. “Dr. Omert served with
distinction as interim director during
Desert Storm, and she is certified by
the American Board of Surgery with
qualification in critical care.”

Three new faculty
members announced

Smego

Two Department of Surgery faculty
members have received national honors.

Dr. Gregory A. Timberlake, associate
professor, was appointed to the
American College of Surgeon’s
Committee on Trauma; and Dr. Daniel
Stewart, assistant professor of plastic and
reconstructive surgery, was certified by
the American Board of Plastic Surgery.

The Department of Microbiology/
Immunology has announced the
appointment of three new faculty.

William R. McCleary, Ph.D, assistant
professor, is from Princeton LIniversity;
and Meenal Elliott, Ph.D., assistant
professor, and Thomas Elliott, Ph.D.,
professor, are from the University of
Alabama in Birmingham.

122 THE WEST VIRGINIA MEDICAL JOURNAL

Daniel Vannoy, JD, announces the opening of Vannoy Law Offices. His legal
practice focuses on business, civil, employment, health care and other areas of the law.

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Robert E. O’Connor, MD
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James W. Caudill, MD
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Cataracts/Lens Implants
Corneal Transplants
Ophthalmic Plastic Surgery
Retinal Surgery
Laser Eye Surgery

OTOLARYNGOLOGISTS
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FAX (304) 353-0215

Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

Students enthusiastic about Rural Physician Associate Program

RPAP student Rodney Sirk examines a young patient at the Lincoln Primary Care Center.

Marshall’s Rural Physician Associate
Program, now in its fourth year,
continues to capture the imaginations
of medical students and rural
preceptors, reports Dr. Linda Savory,
the program’s director.

RPAP, adapted from its namesake at
the University of Minnesota, allows
selected medical students to spend six
to nine months of their third year
assigned to physicians at rural primary
care sites. Students have responded
enthusiastically to the program’s
hands-on emphasis.

“They are expected to carry the ball
as far as they safely can, and, like most
students, they rise to unexpected levels
of competence,” Dr. Savory said. “Rural
preceptors report satisfaction from
student contact, and many become
actively involved in helping to shape
the medical curriculum,” she added.

(Marshall University photo by Rick Haye)

In evaluating their experiences in
Milton, Wayne, Spencer and Scarbro,
students made the following comments:

“I fell as if I would have more control
of my education in the RPAP program . /
have found the program to be one of the
most rewarding experiences of my
medical education. I did indeed feel
that I got a far superior education to my
colleagues who went through the
traditional program. I have also been
responsible fora core of my own
patients for nine months. ”

7 realized how much I was in the real
world of medicine when I entered my
first examining room to a 2-week-old
infant and my second to a 96-year-old
great-grandfather. My initial thought
was, How can 1 schedule my patients
in age-ascending order?' Then 1
realized - - this is family medicine is

all about. Scary? You better believe it
was. But, as time went on and the
nervousness subsided. I could feel a
certain bonding towards these patients
and their families taking effect. ”

“I had a caseload of patients who I
followed on a regular basis. Wloen their
lab work came back, I evaluated this
and made recommendations for
changes in therapy if indicated. In
addition. I was responsible for handling
any problems which occurred between
appointments. When patients were
admitted to the hospital. I was given the
responsibility to assess their problems,
plan the appropriate treatment and
write the hospital orders. ”

“I was able to work with many
different specialists while at the [rural]
hospital, including several family
physicians, two general internists, a
nephrologist, a gastroenterologist, two
general surgeons and an orthopaedic
surgeon. In addition, I also had
consultations with specialists in
infectious diseases, hematology/
oncology and ENT. On many
occasions, these specialists would
catch me in the hospital, introduce me
to patients with interesting problems,
and let me follow their care while they
were in the hospital. ”

“The program also provided the
ability to follow patients over a period
of time, and thus to assess treatment
responses . . . For example, I saw a
75-year-old female that we diagnosed
with diabetes mellitus. We initially
placed her on oral by poglycem ics.
However, as we were unable to control
her blood sugars, we had to place her
on insulin. It has taken nine months for
her to achieve a stable level of diabetes
control. It was quite gratifying to see her
in the office a few days ago and see the
progress she has made ( actually the
progress we both have made!)”

"Today I can say that participating
in RPAP was the best educational
decision I have ever made. ...I have
seen real-life primary care. ’’

124 THE WEST VIRGINIA MEDICAL JOURNAL

You are invited to attend the annual spring meeting of the

West Virginia Academy

West Virginia Academy of Otolaryngology -

Otolaryngology

Head and Neck Surgery, Inc.

The Greenbrier, White Sulphur Springs, WV
May 28 - 30, 1994

Registration F ee: $150 Guest Speakers: Charles W. Cummings, M.D., F.A.C.S.

Apply to:

Kenneth M. Grundfast, M.D., F.A.C.S.

F. Thomas Sporck, M.D.

Fred D. Owens, M.D.

Post Office Box 1628

Charleston, WV 25326-1628

AMA Credit Category I

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Otologist

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OTOLOGY: DISEASES & SURGERY OF THE EAR

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ST. FRANCIS MEDICAL PLAZA • 331 LAIDLEY STREET, SUITE 602 • CHARLESTON, WV 25301

WESPAC News

We would like to thank the
following physicians and alliance
members for their contributions to
WESPAC:

Regular Members
Brooke

William T. Booher

Physicians

A Dollar A Dav Club

Kanawha

Nicholas Cassis Jr.
Thomas W. Poland

*Designates more than $365 in
contributions

Ohio

Jonathan D. Lechner

Cabell

Richard A. Ansinelli
*Willard F. Daniels Jr.
Everett J. Kennedy
Jack Steel

Raleigh

John M. Daniel

Western

Rogelio A. Averion

Kanawha

Chandra M. Kumar
James T. Spencer

Monongalia

James Helsley
Jeffrey A. Stead

Sustainer Members

Greenbrier

Thomas Karrs

Monongalia

David Stoll

Parkersburg Academy

David Waxman

Ohio

Dennis Niess

Western

James S. Kessel

South Branch

Harry L. Eye

Extra Milers

Kanawha

David Abramowitz

Ohio

Richard C. Geary Jr., D.O.

South Branch

Larry C. Rogers

General Contributions

Monongalia

Marian Swinker

Alliance Members

Sustainer Members

Ohio

Donna Niess

Obituaries

J. D. Mathias, M.D.

Dr. J. D. Mathias, M.D., 72, of
Wardensville, died January 4 at Life
Care Center of New Market.

Dr. Mathias was born July 26, 1920,
in Mathias, W.Va. He was retired from
his general practice in Wardensville.

In addition to being a member of the
WVSMA, Dr. Mathias was a member
of the AMA and South Branch Medical
Society.

A veteran of the U.S. Army Medical
Corps, Dr. Mathias was a member of
the Wardensville United Methodist
Church.

Dr. Mathias was the husband of the
late Nellie Maxine Mathias. Surviving
are two sons, Jay Mathias and James
D. Mathias II, both of Wardensville; a
brother, Owen Miller of Wardensville;
two sisters, Andry Mathias and Ann
Morgan, both of Oak Ridge, Tenn.;
and three grandchildren.

Memorial contributions may be
made to the Capon Valley Fire
Company or the Wardensville Rescue
Squad.

Estelito Santos, M.D.

Dr. Estelito Santos, M.D., 56, of
Huntington, died February 12 at
Greenbrier Valley Medical Center.

Dr. Santos was born in Manila,
Philippines, and received his medical
degree from the Far Eastern
University Institute of Medicine. He
interned at North General Hospital
and completed an ob/gyn residency
at Rizal Provincial Training Hospital.

Dr. Santos was president of Emergi-
Care Inc. Prior to this, he was an
emergency room physician at Cabell
Huntington Hospital for 13 years,
where he served as medical director
for five years. During his career,

Dr. Santos had also been a physician
at Huntington State Hospital.

In addition to being a member of
the WVSMA and the Cabell County
Medical Society, Dr. Santos was a
member of the Philippines Medical
Society and the Tri State Fil-Am
Association of West Virginia, Ohio
and Kentucky He was also a member
of Our Lady of Fatima Church.

An avid golfer, Dr. Santos had
attained numerous awards and had
chaired the golf tournament at the
WVSMA’s Annual Meeting for the past
several years.

Survivors include his wife, Corazon
Moreno Santos; two sons, Estelito M.
Santos Jr. and Jose M. Santos, both at
home; one daughter, Lisa M. Santos,
at home; four brothers and one
sister.

126 THE WEST VIRGINIA MEDICAL JOURNAL

Just

WESPAC

Do It!

WESPAC has a new club - the $365 Club, "A
Dollar A Day". Just think about it, a dollar a day
can help reform the health care system and
protect your rights as physicians as well as the
rights of your patients.

Don't wait, the time to act is now!

Send your personal check to WESPAC and
become involved!

WESPAC
P.O. Box 4106
Charleston, WV 25364
304/925-0342

Checks for all PAC contributions should be payable to WESPAC. If
your practice is a corporation or professional association, contribu-
tions must be written on a PERSONAL check. Contributions are not
limited to the suggested amount. Neither the AMA, the WVSMA nor
the component medical societies will favor or disfavor anyone based
on the amount of or failure to make PAC contributions. Contributions
are subject to Federal Election Commission Regulations and the West
Virginia Secretary of State Regulations.

Contributions for WESPAC/AMPAC are not deductible as charitable
contributions for federal income tax purposes. A portion of your
WESPAC contribution is sent to AMPAC thus enrolling you as an
AMPAC member as well.

YOCON'

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5,4 mg of Yohimbine
Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine. though it is
weaker and of short duration. Yohimbine's peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone

Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it, however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage
Indications: Yocon ■ is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac

Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications.

Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.12 Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 A4 1 tablet (5,4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness . In the event of side effects dosage to be reduced to Vi tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon ? 1/12 gr 5.4 mg in

AVAILABLE AT PHARMACIES NATIONWIDE

bottles of 100's NDC 53159-001-01 and 1000's NDC

53159-001-10.

References:

1. A. Morales et al. , New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed. , p 176-188.

McMillan December Rev. 1/85,

3. Weekly Urological Clinical letter, 27:2, July 4,
1983.

4. A. Morales etal., The Journal of Urology 1 28
45-47, 1982.

YOCON*

Rev. 1/85

PALISADES

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West Virginia Medical Journal

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HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
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MARYLAND
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Volume 90 No. 4

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EDITOR

Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR

Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Postmaster send form 3579 to the West
Virginia Medical Journal, 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL IQURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $36 a year in the U.S.;
$60 in foreign countries; $3 per single copy.
Address communications to the West
Virginia Medical Journal, P. O. Box 4106,
Charleston, WV 25364.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Road,
Ann Arbor, MI 48106.

1A Jesl Virginia Medical

OURNAL

Contents

Feature Article

The Health Care Quality Improvement Program:

The WVMI returns to its founding mission

Scientific Newsfront

The value of prostatic specific antigen in prostate cancer

screening in the community

Idiopathic long q-t syndrome:

Brief case report and discussion

Sporadic multiple lipomatosis: A case report and

review of the literature

Manuscript Guidelines

President’s Page

The Bottom Line

Editorial

Managed care

In My Opinion

My answer, or don't confuse me with the facts

Our Readers Speak

More appropriate for the editorial page

Special Departments

General News

WVSMA Annual Meeting Registration Form

Continuing Medical Education

Medical Meetings/Poetry Corner

Bureau of Public Health News

Robert C. Byrd Health Sciences Center of WVU News ....

Marshall University School of Medicine News

Alliance News

New Members/WESPAC Members

Special Memorial/Obituaries

1994 Advertising Rates

Classified

April Advertisers

138

140

143

145

146

148

149

150
151

152

155

156

157

158
160
162
164
166

167

168

169

170

USPS 676 740
ISSN 0043 - 3284

Front Cover

Venus’s Looking Glass, a plant of the Lobelia Family,
blooming in a remote area of Kanawha County. Photo
courtesy of Ron Snow, State of West Virginia, Division of
Natural Resources.

APRIL 1994, VOL. 90 137

Feature Article

Co
prt
to
flf
CO

The Health Care Quality Improvement Program:
The WVMI returns to its founding mission \

HARRY S. WEEKS JR., M.D.

President and Medical Director of the West
Virginia Medical Institute, Charleston; and
Anesthesiologist, Wheeling.

Editor’s Note: Dr. Weeks also
served as president of the West Virginia
State Medical Association from 1971-72.

Abstract

The Health Care Financing
Administration (HCFA ) has launched
an ambitious new program for Peer
Review Organizations ( PROs ) called
the Health Care Quality Improvement
Program (HCQIP). The goal of IICQIP
is to improve the quality of care for
all Medicare beneficiaries through
cooperative interaction between
PROs , providers, and physicians. Tlje
West Virginia Medical Institute,
which serves as the PRO for West
Virginia and Delaware, has recently
begun to implement the changes
required by HCQIP. Tl)is article
explains the various approaches
WVMI will use to achieve the health
care improvement goals set forth by
HCFA.

Introduction

I am reminded of that old saying
“The more things change, the more
they stay the same,” when I think of
how our physician education and peer
review mission has literally come full
circle during my 22 years with the
West Virginia Medical Institute
(WVMI).

When I joined WVMI in 1972, the
organization functioned primarily as
the educational arm of the West
Virginia State Medical Association. In
1984, we were awarded our first
contract from the Health Care
Financing Administration (HCFA) to
serve as the Peer Review Organization
(PRO) for West Virginia, and then in
1986, we were awarded the PRO
contract for Delaware as well.

During the first three PRO contract
cycles or “Scopes of Work” 0984-93),
WVMI’s focus gradually shifted away
from educating the medical community
as a whole toward addressing
individual quality, utilization, and
Diagnostic Related Group (DRG)
concerns relating to the Prospective
Payment System. Under the current
Scope of Work, HCFA has directed the
PROs to move toward identifying
practice patterns that can lead to
comprehensive improvements for the
entire Medicare population. This
“new” educational approach, known
as the Health Care Quality
Improvement Program (HCQIP),
signals a profound shift in HCFA’s
approach to peer review.

Defining the HCQIP

In short, HCQIP is an effort to shift
the focus of the PROs from identifying
individual episodes of substandard
care to identifying patterns that can
result in widespread improvements for
all patients. Under HCQIP, WVMI will
identify providers with the best
practice patterns, and share this
information with other providers to
help them better focus their
educational efforts and improve their
outcomes.

This new approach has brought
about a dramatic change in peer
review methods and affected the
entire scope of WVMI's activities.
Nonetheless, we welcome HCFA’s
shift in philosophy and believe the
health care community will do the
same.

Cooperative projects

WVMI will study patterns of care
and outcomes through national
cooperative projects such as the
Medical Hospital Information Project
(MHIP) and the Cooperative
Cardiovascular Project (CCP), as well
as through locally-developed projects.
The national projects will be
developed by representatives from
HCFA, the Public Health Service,

PROs, health care providers, and

consumers. Each project will have a
specific clinical focus.

MHIP and CCP are the first two
national projects that will be
implemented. MHIP will use
information on hospital mortality rates
to target opportunities for significant
care improvements. CCP will analyze
critical data on Medicare patients
hospitalized for heart attacks, bypass
surgery, and angioplasty. In addition,
the American College of Cardiology’s
practice guidelines will be used to
analyze patterns in the care of acute
myocardial infarction.

WVMI will also develop a number
of local cooperative projects targeted
toward variations in care throughout
West Virginia and Delaware. The
sources of data for these local projects
will include MEDPRO, which is a
HCFA-maintained file containing post-
payment information on all inpatient
Medicare claims, and WVMI’s own
case review data. WVMI has a number
of local projects underway including
studies of the use and timing of
pre-operative antibiotics; the length of
stay for open and laparascopic
cholycystectomies; sepsis coding;
blood transfusions; and community-
acquired pneumonia.

As part of the cooperative project
process, WVMI will select cases and
look only at the issues for which the
cases have been selected. Project data
collection (formerly called “focused
review”) will now be a cooperative,
fact-finding effort with providers.

Educational feedback

Information about patterns of care
will be fed back to individual
providers, and, in aggregate form, to
Medicare beneficiaries and the
medical community as a whole. The
data will come from pattern or case
review analyses at both the provider
and statewide levels.

HCQIP places greater emphasis on
cooperative interaction between PROs,
physicians, hospitals, and medical
staffs. As part of this cooperative
effort, WVMI’s Principal Clinical

138 THE WEST VIRGINIA MEDICAL JOURNAL

Coordinator Dr. Mark Stephens will
provide individual hospital feedback
to each facility’s administrative and
medical staffs. When a pattern of
concern requiring physician feedback
is identified, WVMI will work
cooperatively with the hospital(s) to
improve this pattern. The hospital(s)
will be asked to seek the underlying
factors, outline specific actions to
improve those patterns, and verify
that improvement has occurred.

WVMI will provide statewide
feedback through regular meetings
with hospitals and medical
associations, informational
newsletters, regional seminars, or in
other educational settings.

Case review

WVMI will continue to review
hospital care and ambulatory surgery
for quality, utilization, appropriateness
of setting and validation of DRGs.
Contrary to past practice, review will
be done on a selected sample of
beneficiaries rather than a sample of
cases from selected facilities.

As in the past, all beneficiary
complaints, and, on request, all

hospital-issued notices of non-coverage
will be reviewed. To more effectively
target educational activities, WVMI
will also profile all reviewed cases by
physician, by provider, and for the
entire state.

Other important changes

Other critical changes are as follows:

• The Quality Intervention Plan has
been eliminated. Hospitals and
physicians will no longer be
assigned “points” when quality
problems are identified.

• The quality review process has
changed. WVMI will use an
educational approach to address
patterns and documentation
issues. Preliminary notices of
potential quality concerns will be
less confrontational and will be
sent to the hospital as well as the
attending physician. WVMI will
send notices of final
determinations to physicians and
providers in all cases, regardless
of the outcome. Physicians and
hospitals may ask for re-reviews
of final determinations on quality
issues.

• Pre-procedure review will be
required only for an assistant at
cataract surgery for specific
codes.

• WVMI will coordinate with the
State Medical Board and other
certification and accreditation
bodies to discuss information
sharing and to execute formal
written agreements to assure the
exchange of specific data.

Conclusion

As a practicing physician and
longtime advocate of medical peer
review, I am heartened to see the
WVMI returning to its roots —
educating the medical community and
enhancing the quality of care
provided to all patients.

I hope that physicians and
providers throughout West Virginia
will share our enthusiasm for the new
cooperative, educational approach to
Medicare peer review, and support us
in this significant health improvement
initiative.

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APRIL 1994, VOL. 90 139

cientific Newsfront

The value of prostatic specific antigen in
prostate cancer screening in the community

STEVEN J. JUBELIRER, M.D.

Director of the Cancer Care Center of Southern
West Virginia, CAMC; and Clinical Professor of
Medicine, Robert C. Byrd Health Sciences
Center of WVU, Charleston Division
JAMES P. TIERNEY, D.O.

Clinical Assistant Professor of Urology, Robert
C. Byrd Health Sciences Center of WVU,
Charleston Division

SAMUEL OLIVER, M.D.

Clinical Assistant Professor of Urology, Robert
C Byrd Health Sciences Center of WVU,
Charleston Division

JOSE M. SERRATO, M.D.

Clinical Assistant Professor of Urology, Robert
C Byrd Health Sciences Center of WVU,
Charleston Division

SAMI FARRA, M.D.

Department of Urology, CAMC, Charleston
JOSEPH PLYMALE, M.D.

Former Clinical Assistant Professor of Urology,
Robert C Byrd Health Sciences Center of WVU,
Charleston Division

ERNEST HODGE, M.D.

Fortner Chief of the Renal Transplant Program,
CAMC; and Former Clinical Assistant Professor
of Urology and Surgery, Robert C. Byrd Health
Sciences Center of WVU, Charleston Division

Abstract

At a one-day screening for prostate
cancer in 1991, a urologist evaluated
142 men ages 50 years-84 years
(mean: 67 years) utilizing a digital
rectal exam ( DRE ), serum prostatic
specific antigen (PSA), and a detailed
questionnaire. The 44 men with an
abnormal DRE and/or PSA were
recontacted by letter one year later to
determine the outcome. By 12 months,
31 men (70%) with abnormal findings
had seen a physician as reconmiended
Of the 13 men followed with abnormal
DRE only, three were biopsied with
no cancer found Of the 1 1 with an
elevated PSA only, six were biopsied
and two had cancer. Of the men with
both abnormal PSA and DRE, six
were biopsied and two had cancer.
Thus, after 12 months, the
preliminary cancer detection rate
was 2.8% for the entire study
population, 22% for those with an
elevated PSA, and 10% for those with
an abnormal DRE. The results

suggest that the use of PSA combined
with DRE is a more efficient strategy
for detecting prostate cancer than
DRE alone.

Introduction

Adenocarcinoma of the prostate is
the most common cancer in men,
representing 22% of all cancers and
12% of all male cancer deaths (1).
Approximately 65 percent of prostate
cancers are clinically localized at the
time of diagnosis (2), but only about
half of these prove to be confined to
the prostate at the time of surgery (3).
Thus, nearly two-thirds of cancers have
spread beyond the prostate when first
identified.

Prostatic specific antigen (PSA) is a
serine protease secreted exclusively by
prostatic epithelial cells (4). Elevated
serum levels of PSA have been noted
in 30%-50% of patients with benign
prostatic hyperplasia, and in 25%-92%
of patients with prostate cancer,
depending on tumor volume (5-7).
Measurement of serum PSA is the most
sensitive marker available for monitoring
the progression of prostate cancer and
the response to therapy (5-8). The
value of measuring serum PSA in
addition to the digital rectal
examination (DRE) and transrectal
ultrasound (TRUS) has not received
attention until recently (9).

Measurements of serum PSA
concentration offer several theoretical
advantages over rectal examination or
TRUS in prostate cancer screening. The
result is objective, quantitative,
obtainable independently of the
examiner’s skill, and from the patient’s
point of view, preferable to DRE or
TRUS.

This article describes the preliminary
results of the use of the PSA in prostate
cancer screening at the Charleston Area
Medical Center (CAMC).

Methods and materials

During a one-day screening for
prostate cancer in April 1991, 142 men
were evaluated. Participants were
initially asked to fill out a detailed

questionnaire. Information requested
included the participant’s age, race,
time since last visit to a physician, time
since the last rectal examination,
educational level, urinary complaints,
history of smoking or drinking, family
history of prostate cancer, and prior
history of prostate surgery or prostatitis.

Blood was then drawn for PSA
determination and a DRE was
performed by a urologist. The PSA was
determined using the Tandem-R
(Hybritech, San Diego, Calif.) assay
with 4.0 ng./ml. being utilized as the
upper limit of normal. Those
participants with either an abnonnal
DRE (i.e. asymmetry, induration, or a
nodule) or seaim PSA greater than 4
ng./ml. were referred to their own
urologist or personal physician for
diagnostic procedures or treatment.
Names of local physicians were offered
for individuals without a urologist or
personal physician.

Approximately one year after the
screening, letters were sent to all
clinically positive participants
requesting details about their follow-up
and results of treatment. These persons
were asked whether they had seen a
physician in follow-up, the results of
the biopsy if performed, and the nature
of any treatment. Letters requesting
similar information were also sent to
the patients’ treating physicians. Self-
addressed, stamped envelopes were
included to encourage a response.

Results

There were 142 participants in this
screening. Ninety-seven percent were
Caucasian and 3% were black. Most of
these men were well-educated (32%
graduated high school and 37% had
attended college). Their median age
was 67 years (range 50 years-84 years).
The percent age distribution for the
screened participants was: 50-59 (20%);
60-60 (40%); 70-79 (36%); and > 80
years (4%).

The results from the questionnaire
are shown in Table 1 and indicate that
23% of participants never had a DRE,
and that only 30% had undergone a

140 THE WEST VIRGINIA MEDICAL JOURNAL

TABLE 1. RESULTS OF PATIENT QUESTIONNAIRE

Last Phvsician Exam

Svmotoms

< 1 year

44%

Nocturia

60%

1-2 years

21%

Weak Urine Stream

40%

2-5 years

18%

Dysuria

13%

> 5 years

11%

Bone Pain

Never

3.5%

Pyuria

1.5%

Don't Know

2.5%

Blood in Semen

0.7%

Last Rectal Exam

Family History of Prostate Cancer

< 1 year

30%

13%

1-2 years

16%

2-5 years

16%

> 5 years

15%

Never

23%

Level of Education

Medical History

< 8th Grade

10.5%

Prior Prostate Surgery

10%

Some High School

18%

Enlarged Prostate

30%

High School Grad

32%

Prostatitis

12.5%

Technical School

2.5%

Some College

16%

College Grad

10%

Post Grad

11%

TABLE 2. RESULTS OF FOLLOW UP OF MEN WITH ABNORMAL FINDINGS

Number of Patients Number Biopsied Number With Cancer

Elevated PSA

Abnormal DRE

Elevated PSA

Normal DRE

Nonnal PSA

Abnormal DRE

PSA = Prostatic Specific Antigen
DRE = Digital Rectal Examination

TABLE 3- CLINICAL DETAILS OF MEN WITH PROSTATE CANCER

AGE

PSA

Ng./ML

DRE

STAGE

1 Pathological)

TREATMENT

22.8

Normal

7.2

Abnormal

11.0

Abnormal

5.0

Normal

Radioactive Seeds

RP = Radical Prostatectomy

TABLE 4. RECENT POPULATION STUDIES OF PROSTATE CANCER SCREENINGS USING PSA

Number

0-4.0

>4-10.0

710.0

Detection

Reference

of Men

Ng./ML

Ng./ Ml.

Rate

ACS-NPCDP10

2,229

85.3

11.3

3.4

2.4%

Brawer et aP *

1,249

85.0

11.9

3.0

2.6%

Catalona et al^

1,653

91.7

6.5

1.8

2.2%

Labile et ad4

1,002

87.6

8.9

3.5

5.7%

Cooner et al V

1,807

66.7

20.3

13.0

14.6%

Present Study

142

86.0

12.0

1.4

2.8%

DRE within the previous 12 months.
However, 65% of the participants had
seen a physician within the previous
two years.

Nocturia and a weak urinary stream
were the most common symptoms
encountered (60% and 40% of
participants, respectively). Overall, 30%
of these men had a history of benign
prostatic hyperplasia and 10% had
undergone prostate surgery. No
participant was known to have had
prostate cancer previously, but 13%
indicated a family history of prostate
cancer.

Of all the men tested, 44 (30%) had
suspicious findings (i.e. abnormal DRE
and/or elevated PSA). There were 25
men (17%) with an abnormal DRE
only, 12 (8%) with an abnonnal PSA
only, and seven (5%) with both an
abnonnal DRE and PSA. By 12 months,
31 (70%) of these men had seen a
physician as recommended, but six
refused follow-up and no information
was available for seven of them.

The results of follow-up are shown
in Table 2. Three of the men with an
abnormal DRE were biopsied and no
cancer was found. Of the 11
participants with an elevated PSA only,
six underwent prostatic biopsy and
two had cancer. In addition, of the
seven participants with both an
abnormal PSA and DRE, six were
biopsied and two had cancer. Thus,
after 12 months, the preliminary cancer
detection rate was 2.8% (four of 142)
for the entire study population. The
detection rate for those with an
elevated PSA and for those with an
abnormal DRE was 22% (four of 18)
and 10% (two of 20) respectively.

Subsequently, three of the four men
with prostate cancer underwent radical
prostatectomy and one received
radioactive 1-131 seeds (Table 3). Three
men had organ-confined disease as
determined by pathological
examination.

Discussion

The preliminary overall cancer
detection rate of 2.8% in the screening
using both PSA and DRE is in
accordance with other published
studies (Table 4X10-14). In contrast,
the cancer detection rate in several
large studies of prostate cancer
screening using DRE alone has ranged
from 0.8% to 2.7% (9). With the
exception of the study by Cooner and
his colleagues, the results reported in
Table 4 involved men not under
evaluation for urological complaints (13).

APRIL 1994, VOL. 90 141

All of these five studies focused on
men at ages when prostate cancer risk
is significant, but some difference in
age distribution may account for
differences in cancer findings and PSA
distribution. The study by Labrie et al
(14) yielded a higher cancer detection
rate, possibly because biopsies were
recommended when the PSA exceeded
3.0 ng./ml. and this is a more sensitive
threshold than the 4.0 ng./ml. criterion
used in the other investigations.

It is clear that the serum PSA was
more sensitive than DRE in detecting
prostate cancer. All patients with
cancer in our screening had elevated
levels of serum PSA, whereas only two
had an abnormal DRE. It is impossible
to assess the sensitivity and specificity
of the screening methods used since the
true prevalence of prostate cancer in
our population was not known. Careful
follow-up of these men over many
years may provide the necessary data.

Three of the four cancers detected in
this screening were pathologically
confined to the prostate. Recent PSA
screening studies (10-14) have
indicated that 60%-65% of prostate
cancers detected are [pathologically]
organ-confined. In the most recent
update of the screening program
(1989-92) for Prostate Cancer
Awareness Week (PCAW), Crawford et
al (15) reported that less than 15% and
10% of cancers detected were stage C
and stage D respectively. However,
due to the limited data available at this
time, it remains impossible to predict
whether or not those cancers detected
by screening would have caused
symptoms or even death if they had
been left untreated.

Several studies have addressed the
problem of the natural history of
localized prostate cancer (16, 17). These
studies have shown that the two most
important factors in predicting the
behavior of a localized prostate cancer
are the volume and histological grade
of the tumor. Although these factors
are important when groups of patients
are studied, it remains impossible to
predict with any accuracy the chances
of local progression or metastatic
spread of any individual cancer.

Several aspects about the
interpretation of our data are
important. First of all, our data
provides little evidence of benefit to
the participants. Our results, as well as
those from other published studies,
provide no information about the value
of screening in reducing prostate
cancer morbidity and mortality.

Secondly, the group of men examined
represent a self-selected population. The
majority of participants were
Caucasian, had seen a physician in the
past two years, were high school or
college graduates, and had some
urinary symptoms. These findings
mirror the broader national subjects
that have participated in the PCAW
screenings since 1989 (15). The
Prostate Cancer Education Council has
found that these self-selected
populations are overwhelmingly
Caucasian, more highly educated than
the national average, have regular
health check-ups, and may have been
prompted to participate in prostate
cancer screening by some urologic
symptoms. We have no infonnation on
persons who chose not to participate in
our screening. Since volunteer
populations may not completely reflect
the characteristics of the population of
men at risk of prostate cancer, we are
limited in our generalization of these
findings beyond the group studied.

In addition, our data provided little
insight concerning the cost-effectiveness
of screening for prostate cancer. This is
an issue that was addressed in a study
by Littaip and colleagues (18), which
suggests that, economically at present,
the combination of DRE and PSA at
4 ng./ml. provides the best approach to
potentially decrease prostate cancer
mortality. Although our screenings were
conducted with little or no direct cost to
the participants, the aggregate value of
the health services involved is
substantial and is a subject for further
study.

Despite the limitations of our study
which I have descibed, our data adds
to the increasing evidence that DRE
alone can no longer be considered the
sole means of detecting prostate cancer.
Although the serum PSA is an imperfect
screening test, when combined with
DRE, it increases the rate of detection
of prostate cancer.

Acknowledgements

The authors would like to thank
Dianne Knight of the Department of
Medicine at the Robert C. Byrd Health
Sciences Center of WVU, Charleston
Division, for her technical expertise in
the preparation of this manuscript.

References

1 . Boring CC, Squires TS, Tong T. Cancer
Statistics 1993; CA Cancer J Clin 1993;43:7-26.

2. Mettlin C, Jones GW, Murphy GP Trends in
prostate care in the United States, 1974-1990:
Observations from the patient care
evaluation. Studies of the American College
of Surgeons Commission on Cancer. CA
Cancer J Clin 1993;43:83-91.

3. Catalona WJ, Bigg SW. Nerve-sparing radical
prostatectomy; evaluation of results after 250
patients. J Urol 1990; 143:538-43.

4. Nadji M, Tabei SJ, Castro A, et al. Prostate
specific antigen: An immuno-histologic
marker for prostatic neoplasms. Cancer
1981;48:1229-32.

5. Stamey TA, Yang N, Hay AR, McNeal JE,
Freiha FS, et al. Prostate-specific antigen as a
serum marker for adenocarcinoma of the
prostate. N Engl J Med 1987;317:909-16.

6. Hudson MA, Bahnson RR, Catalona WJ.
Clinical use of prostate specific antigen
in patients with prostate cancer. J Urol
1989;142:1011-7.

7. Partin AW, Carter HB, Chan DW, et al.
Prostate-specific antigen in the staging of
localized prostate cancer: Influence of tumor
differentiation, tumor volume and benign
hyperplasia. J Urol 1990;143:747-52.

8. Killian CS, Emrich LJ, Vargas FP, et al.
Relative reliability of five serially measured
markers for prognosis of progression in
prostate cancer. J Natl Cancer Inst 1986;
76:179-85.

9. Gerber GS, Chodak GW. Screening and the
early detection of prostate cancer. Advances
in Oncology 1993;9(4):9-12.

10. Mettlin C, Lee F, Drago J, Murphy GP, and
the members of the American Cancer Society -
National Prostate Cancer Detection Project.
Findings on the detection of early prostate
cancer in 2,425 men. Cancer 1991;67:2949-58.

11. Brawer MK, Chetner MP, Beatie J, Buchner
DM, Vessella RL, Lange PH. Screening for
prostatic carcinoma with prostate specific
antigen. J Urol 1992;147:841-5.

12. Catalona WJ, Smith DS, Ratliff TL, Dodds
KM, Coplen DE, Yuan JJJ, et al. Measurement
of prostate specific antigen in serum as a
screening test for prostate cancer. N Eng J
Med 1991;324:1156-61.

13- Cooner WH, Mosley BR, Rutherford CL Jr,
Beard JH. Pond HS, Terry WJ, et al. Prostate
cancer detection in a clinical urological
practice by ultrasonography digital rectal
examination and prostate specific antigen. J
Urol 1990;143:1146-54.

14. Labrie F, Dupant A, Suburu R, Cusan L,
Tremblay, et al. Serum prostate specific
antigen as pre-screening test for prostate
cancer. J Urol 1992;147:846-52.

15. Crawford ED, DeAntoni EP, Stone NN, Blum
DS, et al. Prostate Cancer Awareness Week,
1989-1992: Lessons in the early detection of
prostate cancer [abstract]. Proc Am Soc Clin
Oncol 1993:12:769.

16. George NJR. Natural history of localized
prostate cancer managed by conservative
therapy alone. Lancet 1988;1:494-7.

17. Johansson J, Anderson S, Krusemo UB, et al.
Natural history of localized prostate cancer.
Lancet 1989;1:799-803.

18. Littrup PJ, Goodman AC, Mettlin CJ. The
investigators of the American Cancer Society -
National Prostate Cancer Detection Project.
The benefit and cost of prostate cancer early
detection. CA Cancer J Clin 1993;43:134-49-

—

142 THE WEST VIRGINIA MEDICAL JOURNAL

Idiopathic long q-t syndrome: Brief case report
and discussion

WILLIAM E. NOBLE, M.D., F.A.C.C.

Associate Professor, Department of Medicine,
Robert C. Byrd Health Sciences Center of WVU,
Morgantown, W.Va.

PRADIPTA CHAUDHURI, M.D.

PGY-I1, Department of Internal Medicine,

Ohio Valley Medical Center. Wheeling, W. Va.

MUBASHIR A. QAZI, M.D.

PGY-I11, Department of Internal Medicine,
Ohio Valley Medical Center, Wheeling, W. Va.

Abstract

Idiopathic long q-t syndrome
(LQTS) is an infrequently occurring
familial disorder in which affected
family members have an abnormally
prolonged q-tc interval with
syncope, ventricular arrythmias and
sudden death. In this article, we
present the case of a 54-year-old
female admitted for syncope, who
was on no medications except for
insulin. Her electrocardiogram on
admission had prolonged q-tc
internal ( 0.50 ms.). She had repeated
episodes of torsades de pointes
during her hospitalization, which
were later controlled by beta-
blockers. Electrocardiograms of her
mother and daughter showed
asymptomatic prolonged q-tc
interval. This syndrome has an
autosomal dominant pattern of
transmission and it was first
described by Romano and Ward in a
patient with normal hearing. Our
case is unusual because this
condition presented so late in life.

Introduction

The q-t interval in an
electrocardiogram is a readily
available index of the time required
for ventricular activation and recovery
of excitability. The upper limit for q-t
interval when corrected for heart rate
by Bazett’s formula (1) is 0.44 ms.

The phenomenon of delayed
repolarization causing prolongation of
the q-t interval is categorized into
idiopathic long q-t syndrome (LQTS)
and acquired types.

The idiopathic form has strong
familial patterns suggesting genetic
mechanism of inheritance. About 10%
of the reported cases are of the
sporadic non-familial type. The
heritable form has been mostly noted

in the age group of infants to young
adolescents.

This article presents the first reported
case of LQTS where the patient
remained asymptomatic until her fifth
decade of life, which is unusual.

Case report

A 54-year-old black female with a
history of syncope was admitted to
Ohio Valley Medical Center after
leaving an emotional church sermon.
Before this event, she had described a
feeling of palpitations.

This patient had normal hearing and
her past medical history revealed that
she had experienced recurrent
dizziness without loss of conciousness
within the past three years, as well as
diabetes mellitus which required insulin.
She had also been diagnosed with
non-Hodgkins lymphoma in 1991.

Electrocardiogram showed
prolonged q-t interval (q-tc 0.50 ms.).

A large retroperitoneal mass along
with some enlarged lymph nodes in
the neck were noted. Serum electrolytes
and a CT scan of the brain were

normal. Echocardiogram showed mild
left atrial enlargement and normal
ejection fraction of the left ventricle.
Also, intracardiac masses were
excluded and valve motion was
normal.

This patient developed recurrent
episodes of torsades de pointes
(Figure 1) and ventricular tachycardia
during her hospitalization, which were
finally controlled with intravenous
magnesium and bretylium. Serial
electrocardiograms showed persistent
prolonged q-t interval and she was
discharged home on oral propranolol.

During follow-up as an outpatient,
her q-t interval was noted to be
borderline prolonged (q-t 0.45 s.).
Electrocardiograms of the mother and
daughter showed borderline
prolonged q-t intervals (q-tc 0.45 ms.).

Discussion

LQTS was first described in 1957 by
Jervell and Lange-Nielsen (2). Their
case involved a Norwegian family
where four of the six siblings had
congenital deafness, syncope and

Figure 1. Admission electrocardiogram of the patient at rest demonstrating the prolonged q-t
intervaL Rhythm strips show torsades de pointes in the same patient in the cardiac care unit.

APRIL 1994, VOL. 90 143

Pacemaker Pacemaker Yearly Follow-up

Stellectomy

Figure 2. Algorithm for managing patients identified as having long q-t syndrome (LQTS).
[Increase, Decrease, HX, History, ECG, Electrocardiogram],

sudden deaths, and several similar
cases were later reported. All of the
patients in these cases had severe
bilateral high-frequency deafness and
structurally normal hearts.

This type of LQTS is considered to
have an autosomal recessive form of
inheritance with pleiotropic expression
of the gene. The heterozygote is either
clinically normal or has asymptomatic
slight prolongation of the q-t interval.

In 1963, Ward (3) described a case of
syncope associated with prolonged q-t
interval, ventricular arrythmias and
sudden death, but normal hearing.
Numerous cases have since been
described in literature and an autosomal
dominant pattern of inheritance has
been proposed. In 1979, a worldwide
prospective registry of patients with
LQTS was established for follow-up and
to evaluate the efficiency of therapeutic
interventions (4).

The clinical hallmarks of this
condition are recurrent syncope,
prolonged q-tc interval, family history
of sudden deaths or syncope. Syncope
has been known to be preciptated by
intense emotions such as anger or fright,
intense physical activity and occasionally
with auditory stimuli. Frequently
patients with long q-t syndrome have
resting bradycardia, and exercise testing
has revealed either failure of the q-t
interval to shorten during exercise or
exaggerated q-t prolongation in the
recovery phase after exercise (5).

Holter monitoring of patients with
history of syncope and prolonged q-t
interval, has often revealed episodes of
bradycardia, transient ventricular
arrythmias and episodic t-wave
alternans characteristic of this disorder.

Patients of all ages presenting with
abrupt syncope, especially children,
should have an electrocardiogram
obtained and a careful family history of
recurrent syncope or premature sudden
death recorded. If positive family history
of sudden death exists, then
electrocardiograms of first degree
relatives should be obtained. The risk
of sudden death in patients with LQTS
and unexplained syncope is about 5% a
year It is difficult, however, to predict
which patients with an initial episode
of transient ventricular arrythmias will
go on to have a fatal outcome. Data
collected thus far suggests that the
highest mortality rates are found in
individuals with electrocardiographic
t-wave alternans, or those with a
prolonged q-tc interval greater than
0.54 ms. or repetitive ventricular
arrythmias (6).

The accepted hypothesis for the
pathogenesis of this condition is felt to
be due to sympathetic imbalance
between cardiac sympathetic nerves of
the right and left side of the heart (7).
This has been mimicked in dogs where
right-sided stellectomy decreased
ventricular fibrillation and left-sided
stellectomy increased the ventricular

fibrillation threshold giving a protective
effect (8).

Present management has focused on
beta blockers with a high degree of
success in most symptomatic patients.
The main goal of therapy has been to
prevent recurrence of torsades de
pointes and syncope. All antiarrythmic
agents as a rule are generally avoided
in treating LQTS.

In patients who suffer from
excessive bradycardia on beta blockers
or have recurrence of syncope, left
stellate ganglionectomy has produced
consistent disappearance of syncopal
episodes on follow-up (9). In refractory
cases, permanent cardiac pacing (atrial
or ventricular) combined with beta
blockers has succeeded in preventing
symptoms in a small subset of patients
(10). Lifelong therapy has been
advocated, as little data is available to
show prognosis in discontinuation of
therapy after patients have been
rendered asymptomatic or their q-tc
interval has returned to nonnal (less
than 0.44 ms).

Summary algorithms for
management of LQTS patients are
presented in Figure 2 and in an article
by Moss and Robinson (11).

References

1. Bazett HC. An analysis of the time relations
of electrocardiogram. Heart 1920;7:353-70.

2. Jervell A, Lange-Nielson F. Congenital deaf
mutism functional heart disease with
prolongation of the q-t interval and sudden
death. Am Heart J 1957;54:59-68.

3. Ward O. A new familial cardiac syndrome
in children. J Irish Med Assoc 1964;54:103-6.

4. Moss AJ, Schwartz PJ, Crampton RS, Locati
EH, Carleen E. The long qt syndrome: a
prospective international study. Circulation
1985;71:17-21.

5. Benhorin J, Hewitt D, Moss AJ. Relationship
between repolarization duration and cycle
length during exercise testing in normals
and long qt syndrome patients. J Am Coll
Cardiol 1991;84:17(2A).

6. Moss AJ, Schwartz PJ, Crampton RS, et al.
The long q-t syndrome:prospective
longitudinal syndrome of 328 families.
Circulation 1991;84:1136-1144.

7. Ueda H, Zanac Y, Maras S, et al.
Electrocardiographic and vectorcardiographic
changes produced by electrical stimulation
of cardiac nerves. Jap Heart J 1964;5:359.

8. Schwartz PJ, Snebold NG, Brown AM.

Effects of unilateral cardiac sympathetic
denervation on the ventricular fibrillation
threshold. Am J Cardiol 1976;37:1034-40.

9- Schwartz PJ, Locati EH, Moss AJ, et al. Left
cardiac sympathetic denervation in the
therapy of the congenital long qt syndrome:
a worldwide report. Circulation 1991;
84:503-11.

10. Eldar M, Griffin JC, Abbott JA, et al.
Permanent cardiac pacing in patients with
long qt syndrome. J Am Coll Cardiol 1987;
10:600-7.'

1 1 . Moss AJ, Robinson JL. Long qt syndrome.
Heart Disease and Stroke 1992;1:309-14.

144 THE WEST VIRGINIA MEDICAL JOURNAL

Sporadic multiple lipomatosis: A case report
and review of the literature

DAVID WILSON, MSIV

Robert C. Byrd Health Sciences Center of WVU,
Morgantown, W.Va.

JAMES BOLAND, M.D.

Robert C. Byrd Health Sciences Center of WVU,
Charleston Division

Abstract

The finding of multiple lipomas , or
lipomatosis, can be a marker for
several clinical or familial syndromes.
Familial multiple lipomatosis is a
benign hereditary’ disorder of
adipose regulation associated with
hyperlipidemia. Multiple symmetric
lipomatosis involves the local
infiltration of adipose tissue of the
neck, upper torso and mediastinum.
This condition is often found in
alcoholics and has been associated
with diabetes mellitus. An afflicted
patient’s family history is important
both to reveal occult pathology' and
to help determine the disease’s
prevalence in the population. In this
article, we report the case of a patient
with sporadic multiple lipomatosis
and provide a brief review of the
literature.

Introduction

Lipomas are the most common soft
tissue tumor. They comprise almost
one half of benign soft tissue tumors
and are usually discovered by accident
since there are usually no symptoms (1).
The occurrence of multiple lipomas,
or lipomatosis, in a patient, however,
can be a marker for several clinical or
familial syndromes.

In this article, a patient with sporadic
multiple lipomatosis will be presented
along with a brief review of the
literature.

Case report

A 49-year-old black male presented
to the General Surgery Clinic at the
Memorial Division of CAMC in
Charleston with a history of multiple
painful lipomas which he reported had
been increasing in size. He first noticed
the masses at age 29. Most were
painless, and occurred on the trunk.
Several, though, on his lower back were
painful, and he had these removed
surgically in 1985 without complications
or evidence of malignancy.

For approximately the next five
years, this patient was asymptomatic.
He then began noticing firm, painful
masses over his upper abdomen,
lower chest and inguinal regions
bilaterally. Several other masses were
non-tender.

The patient said he did not know of
any other members of his family
having lipomas. He also denied prior
local trauma, alcohol abuse, periods of
rapid weight gain or loss, diabetes
mellitus, or other endocrinologic
disease. He was being treated for
depression.

Physical exam revealed a well-
developed. non-obese black male.

The lipomas ranged in size from 1 cm.
to 3 cm., and were located in a
distribution involving the trunk, lower
back and inguinal regions bilaterally.
The neck, face and extremities were
spared. The lipomas over the sternum,
upper abdomen, and in the groin
were tender to palpation.

A total of 13 masses were removed
under general anesthesia. Pathologically,
six specimens were lipomas and seven
were found to be angiolipomas. There
was no evidence of malignancy.

Discussion

Multiple lipomas occur in 1% - 7%
of patients with lipomas. They most
often present in the fifth and sixth
decades and are more common in
men than women. They often occur
during periods of rapid weight gain,
and are more common in obese
patients (2).

Angiolipomas can occur
sporadically, in conjunction with
lipomas, or in families (3). These
benign, painful nodules consist of
mature adipose tissue and
proliferating capillaries in varying
proportions (4).

Two distinct, but sometimes
confused, clinical syndromes of
multiple lipomas have been reported --
familial multiple lipomatosis (FML)
and multiple symmetric lipomatosis
(MSL). FML has a strong familial
component that is characterized by
multiple discrete encapsulated
lipomas. MSL is also believed by some
to be familial (5), but this syndrome
involves diffuse fatty infiltration of the
neck, shoulder, and interscapular
tissues.

FML is believed to be an autosomal
dominant syndrome with incomplete
penetrance (6). It is characterized by
multiple smooth, round to ovoid non-
tender subcutaneous nodules that are
found on the forearms, arms, trunk
and thighs. The prevalence of FML in
the general population is unknown.

The masses characteristically reach a
maximal size of between 0.5 cm. and
6.0 cm. after an initial period of rapid
growth. The tumors rarely
spontaneously regress, and in fact,
their volume has been observed to
persist through periods of emaciation.
This is due to a deficiency in
lipoprotein lipase (3). They are stated
to never undergo malignant change
(1), however, cases of liposarcomas
have been reported in patients with a
history of subcutaneous lipomas (7).

FML was first reported in 1846 by
Brodie (6). Since then, the syndrome
has been reported under various names
including “discrete lipomatosis,” “non-
symmetric subcutaneous lipomatosis,”
and “multiple circumscribed lipomas.”
FML has been associated with other
diseases, but its etiology is not well
understood. Cases of lipomas arising
from sites of prior trauma have been
reported (6), and links to
neurofibromatosis, diabetes mellitus
and MEN syndromes have been
suggested (3,6). Lipomatosis can be a
feature of Gardner’s Syndrome, and in
1989, Rubinstein reported a family with
FML in which the affected members
also had hypercholesterolemia (8).

The diagnosis of FML is clinical, but
can be confirmed by excisional
biopsy. Treatment of these benign
tumors is primarily conservative, and
indications for surgical removal are
pain (angiolipomas) and for cosmesis.
The recurrence rate is approximately
5% (2).

MSL was first reported in 1888 by
Madelung who described an
infiltrating adipose hyperplasia around
the neck and shoulders of male
brewery workers. This syndrome is
well defined and is known alternately
as “benign symmetric lipomatosis,”
“Madelung’s disease,” or “Launois-
Bensaude adenolipomatosis.”
Associated with alcoholism, MSL
occurs four times more commonly in
males.

The symmetric distribution of bulky
infiltrating subcutaneous adipose

APRIL 1994, VOL. 90 145

tissue of the neck, interscapular
region and mediastinum is a
consistent feature of MSL. Peripheral
and autonomic neuropathies
independent of the alcoholism are
also observed, and space-occupying
mediastinal syndromes often coexist
(5). In 40%-60% of the patients,
adipose hyperplasia of the abdomen,
hips, arms and thighs mimicking
simple obesity is seen, and one case
of malignant degeneration has been
reported (9).

Approximately 200 patients have
been reported with MSL. This disorder
has been extensively studied as a
model for adipose regulation, and is
characterized as a triglyceride storage
disease. Increased lipoprotein lipase
activity, decreased adrenergic-
stimulated lipolysis, brown adipose
ultrastructural features, and
mitochondrial dysfunction have been
reported (5,10,11).

Treatment for MSL involves surgical
resection to prevent airway compromise

and mediastinal compression. Both
open surgical excision and liposuction
have been extensively reported (12).

For both FML and MSL, the finding
of abnormal adipose distribution or
multiple masses consistent with
lipomas can be a marker for occult
pathology. A careful family history
with appropriate screening of family
members should be pursued to help
better define the prevalence of both
FML and MSL in the population.

References

1. Kissane J. Anderson’s Pathology. Vol. 2. St.
Louis: Civ. Mosby Co., 1990:1879.

2. Enzinger F. Soft Tissue Tumors. St. Louis:
C.V. Mosby Co., 1989:305.

3. Osment LS. Cutaneous lipomas and
lipomatosis. Surg Gynecol Obstet 1968;
127:129.

4. Haustein Uf, Uhl J. Multiple bluish
subcutaneous nodules: Multiple angiolipomas.
Arch Dermatol 1990; 126:666.

5. Enzi G. Multiple symmetric lipomatosis: an
updated clinical report. Medicine 1984;63:56.

6. Leffell DJ, Braverman IM. Familial multiple
lipomatosis: report of a case and a review
of the literature, f Am Acad Dermatol 1986;
15:275.

7. Barkhof F, Melkert P, Meyer S, Blomjous CE.
Derangement of adipose tissue: a case
report of multicentric retroperitoneal
liposarcomas, retroperitoneal lipomatosis
and multiple subcutaneous lipomas. Eur J
Surg Oncol 1991;17:547.

8. Rubinstein A, Goor Y, Gazit E, Cabili S.
Non-symmetric subcutaneous lipomatosis
associated with familial combined
hyperlipidemia. Br J Dermatol 1989;120:689.

9. Tizian C, Berger A, Vykoupil KF. Malignant
degeneration in Madelung’s disease (benign
lipomatosis of the neck): case report. Br J
Plast Surg 1983;36:187.

10. Berkovic SF, Andermann F, Shoubridge EA,
Carpenter S, Robitaille Y, Andermann E, et
al. Mitochondrial dysfunction in multiple
symmetric lipomatosis. Ann Neurol 1991;
29:566.

11. Zancanaro C, Sbarbati A, Morroni M,

Carraro R, Cigolini M, Enzi G, et al. Multiple
symmetric lipomatosis: ultrastructural
investigation of the tissue and preadipocytes
in primary culture. Lab Invest 1990;63:253.

12. Boozan JA, Maves MD, Schuller DE.

Surgical management of massive benign
symmetric lipomatosis. Laryngoscope 1992;
102:94.

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Where reference is made to generically-designated
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146 THE WEST VIRGINIA MEDICAL JOURNAL

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FOR THE NASAL AND
NON-NASAL SYMPTOMS
OF SEASONAL
ALLERGIC RHINITIS

Clear Choice In
Antihistamine

Therapy

Proven efficacy

Nonsedating

The incidence of sedation with
CLARITIN Tablets (8%) was similar
to that of placebo (6%) at the
recommended dose.

Rapid-actingf

CLARITIN Tablets started working
in some patients in as soon as
30 minutes; 65% of patients
experienced relief within 2 hours. ’

• Once-a-day dosing

• Low incidence of adverse effects

Clear Benefits
From Start To Finish

In controlled clinical trials using the recommended dose, the
incidence of headache (12%), somnolence (8%), fatigue (4%),
and dry mouth (3%) with CLARITIN Tablets was similar to that
of placebo (11%, 6%, 3%, and 2%, respectively).

• Over 1 billion patient days of
worldwide experience

' In studies with CLARITIN Tablets at doses 2 to 4 times higher than the recommended dose
of 10 mg. a dose-related increase in the incidence of somnolence was observed.

t Relief began in 13% of treated patients vs 4% of placebo-treated patients within
30 minutes (P=.04). At 2 hours, 48% of patients receiving placebo experienced relief.
Distribution of onset times was significantly earlier for CLARITIN Tablets vs placebo (P-.03).

Once-a-day

Claritin

smdoratadine)

III

Please see following page for brief summary of Prescribing Information.

CLARITIN*
brand ot loratadine
TABLETS

Long-Acting Antihistamine
BRIEF SUMMARY

(For full Prescribing Information, see package insert.)

INDICATIONS AND USAGE

CLARITIN Tablets are indicated for the relief of nasal and non-nasal symptoms of seasonal allergic rhinitis

CONTRAINDICATIONS

CLARITIN Tablets are contraindicated in patients who are hypersensitive to this medication or to any of its ingredients

PRECAUTIONS

General: Patients with liver impairment should be given a lower initial dose (10 mg every other day) because they have reduced
clearance of CLARITIN Tablets.

Drug Interactions: The coadministration of a single 20 mg dose of CLARITIN Tablets (double the recommended daily dose) and
a 200 mg dose of ketoconazole twice daily to 12 subjects resulted in increased plasma concentrations of loratadine (180%
increase in AUC) and its active metabolite, descarboethoxyloratadme (56% increase in AUC). However, no related changes were
noted in the QTc on ECGs taken at 2. 6. and 24 hours after the coadministration of loratadine and ketoconazole Also, there were
no significant differences in clinical adverse events between CLARITIN Tablet groups with or without ketoconazole.

Other drugs known to inhibit hepatic metabolism should be coadministered with caution until definitive interaction studies
can be completed. The number of subjects who concomitantly received macrolide antibiotics, cimetidme. ranitidine, or theo-
phylline along with CLARITIN Tablets in controlled clinical trials is too small to rule out possible drug-drug interactions There
does not appear to be an increase in adverse events in subjects who received oral contraceptives and CLARITIN Tablets com-
pared to placebo

Carcinogenesis. Mutagenesis, and Impairment of Fertility: In an 18-month oncogenicity study in mice and a 2-year study in
rats, loratadine was administered in the diet at doses up to 40 mg/kg (mice) and 25 mg/kg (rats) in the carcinogenicity studies,
pharmacokinetic assessments were carried out to determine animal exposure to the drug AUC data demonstrated that the expo -
sure of mice given 40 mg/kg of loratadine was 3 6 (loratadine) and 18 (active metabolite) times higher than a human given
10 mg/day. Exposure of rats given 25 mg/kg of loratadine was 28 (loratadine) and 67 (active metabolite) times higher than a
human given 10 mg/day Male mice given 40 mg/kg had a significantly higher incidence of hepatocellular tumors (combined
adenomas and carcinomas) than concurrent controls. In rats, a significantly higher incidence of hepatocellular tumors (com-
bined adenomas and carcinomas) was observed in males given 10 mg/kg and males and females given 25 mg/kg The clinical
significance of these findings during long-term use of CLARITIN Tablets is not known
In mutagenicity studies, there was no evidence of mutagenic potential in reverse (AMES) or forward point mutation
(CHO-HGPRT) assays, or in the assay for 0NA damage (Rat Primary Hepatocyte Unscheduled DNA Assay) or in two assays for
chromosomal aberrations (Human Peripheral Blood Lymphocyte Clastogenesis Assay and the Mouse Bone Marrow Erythrocyte
Micronucleus Assay). In the Mouse Lymphoma Assay, a positive finding occurred in the nonactivated but not the activated
phase of the study

Loratadine administration produced hepatic microsomal enzyme induction in the mouse at 40 mg/kg and rat at 25 mg/kg, but
not at lower doses

Decreased fertility in male rats, shown by lower female conception rates, occurred at approximately 64 mg/kg and was
reversible with cessation of dosing Loratadine had no effect on male or female fertility or reproduction in the rat at doses of
approximately 24 mg/kg

Pregnancy Category B There was no evidence of animal teratogenicity in studies performed in rats and rabbits There are. how-
ever. no adequate and well-controlled studies in pregnant women Because animal reproduction studies are not always predic-
tive of human response. CLARITIN Tablets should be used during pregnancy only if clearly needed
Nursing Mothers Loratadine and its metabolite, descarboethoxyloratadme. pass easily into breast milk and achieve concentra-
tions that are equivalent to plasma levels with an AUC^/AUC^^ ratio of 117 and 0.85 for the parent and active metabolite,
respectively Following a single oral dose of 40 mg. a small amount of loratadine and metabolite was excreted into the breast
milk (approximately 0.03% of 40 mg over 48 hours). A decision should be made whether to discontinue nursing or to discon-
tinue the drug, taking into account the importance of the drug to the mother Caution should be exercised when CLARITIN
Tablets are administered to a nursing woman

Pediatric Use: Safety and effectiveness in children below the age of 12 years have not been established

ADVERSE REACTIONS

Approximately 90.000 patients received CLARITIN Tablets 10 mg once daily in controlled and uncontrolled studies Placebo -
controlled clinical trials at the recommended dose of 10 ma once a day varied from 2 weeks' to 6 months' duration The rate of
premature withdrawal from these trials was approximately 2% in both the treated and placebo groups

REPORTED ADVERSE EVENTS WITH AN INCIDENCE OF MORE THAN 2% IN
PLACEBO-CONTROLLED ALLERGIC RHINITIS CLINICAL TRIALS
PERCENT OF PATIENTS REPORTING

LORATADINE

10 mg QD
n = 1926

PLACEBO

n = 2545

CLEMASTINE

1 mg BID
n = 536

TERFENADINE

60 mg BID
n = 684

Headache

Somnolence

Fatigue

Dry Mouth

Adverse event rates did not appear to differ significantly based on age. sex. or race, although the number ot non -white sub-
jects was relatively small.

In addition to those adverse events reported above, the following adverse events have been reported in 2% or fewer patients
Autonomic Nervous System Altered salivation, increased sweating, altered lacrimation, hypoesthesia. impotence, thirst, flushing
Body As A Whole Conjunctivitis, blurred vision, earache, eye pain, tinnitus, asthenia, weight gam back pain, leg cramps,
malaise, chest pain, rigors, fever, aggravated allergy, upper respiratory infection, angioneurotic edema
Cardiovascular System Hypotension, hypertension, palpitations syncope tachycardia

Central and Peripheral Nervous System Hyperkinesia, blepharospasm, paresthesia, dizziness, migraine, tremor, vertigo,
dvsphonia

Gastrointestinal System Abdominal distress, nausea, vomiting, flatulence, gastritis, constipation, diarrhea, altered taste,
increased appetite, anorexia, dyspepsia, stomatitis, toothache.

Musculoskeletal System Arthralgia, myalgia

Psychiatric Anxiety, depression, agitation, insomnia, paroniria. amnesia, impaired concentration, confusion, decreased libido,
nervousness

Reproductive System Breast pain, menorrhagia, dysmenorrhea, vaginitis

Respiratory System Nasal dryness, epistaxis pharyngitis, dyspnea nasal congestion, coughing, rhinitis, hemoptysis, sinusitis,
sneezing, bronchospasm, bronchitis, laryngitis

Skin and Appendages Dermatitis, dry hair dry skin, urticaria, rash, pruritus, photosensitivity reaction, purpura.

Urinary System Urinary discoloration, altered micturition

In addition, the following spontaneous adverse events have been reported rarely during the marketing of loratadine
peripheral edema, abnormal hepatic function, including jaundice, hepatitis, and hepatic necrosis, alopecia, seizures, breast
enlargement: erythema multiforme, and anaphylaxis.

OVEROOSAGE

Somnolence, tachycardia, and headache have been reported with overdoses greater than 10 mg (40 to 180 mg). In the event of
overdosage, general symptomatic and supportive measures should be instituted promptly and maintained for as long as necessary
Treatment of overdosage would reasonably consist of emesis (ipecac syrup), except in patients with impaired consciousness,
followed by the administration of activated charcoal to absorb any remaining drug If vomiting is unsuccessful, or contra-
indicated. gastric lavage should be performed with normal saline Saline cathartics may also be ot value for rapid dilution of
bowel contents Loratadine is not eliminated by hemodialysis It is not known if loratadine is eliminated by peritoneal dialysis.

Oral LDjq values for loratadine were greater than 5000 mg/kg in rats and mice Doses as high as 10 times the recommended
clinical doses showed no effects in rats. mice, and monkeys.

Schermg Corporation
Kenilworth NJ 07033 USA

Rev 9/93

17790803-JBS

c~ j i

/IS)/

Reference

1. Bedard P-M. Del Carpio J, Drouin MA, et al. Onset of action of loratadine and placebo and
other efficacy variables in patients with seasonal allergic rhinitis.

Clin Ther. 1992;14:268-275.

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a patient coined it. “O.K. doc, I know
I’m sick but just give me the bottom
line.”

Regardless of where it was first
used, the bottom line is a phrase
which has been showing up recently
in many conversations and generally it
is used in these four ways:

1. The difference between income
and expenses.

2. The final number in a financial
deal after much pencil sharpening.

3. The final result after studying a
complex situation.

4. The limit to which one is willing
to compromise.

President's Page

The Bottom Line

The fourth use has been the way
this term has been showing up in
many medical conversations lately. I
don’t mean in discussions about
patient care (which we seem to have
less of recently), but in conversations
with insurance companies who will
now be competing for your
participation. We may find physicians
in heavy competition for participation
in some insurance plans that will try
to limit the panel of physicians
offered as a method to control cost.

Unfortunately, physicians are not
very good pencil sharpeners. We tend
to spend most of our time thinking
about patient care — or try to at least.

I believe that when President Clinton
talks about the retraining of
physicians he may also be including
“Pencil Sharpening 101.”

With all this talk of competition,
will patient populations become
commodities that will be traded to the
lowest or highest bidder? It may
become common to move from
insurance plan to insurance plan, or

from physician to physician annually
(or more often), based on who gets or
gives the better deal. Some of these
deals may be based on things that
have nothing to do with patient care,
such as future rights to a network or a
first-round pick in the 1998 Primary
Physician Draft.

There is no doubt that you will be
or have been in some of these
negotiations already. We have to resist
the urge to turn patients into
commodities that will be bargained
for, or physicians into players with
agents looking for a piece of the
action.

Remember that your bottom line
has been and will always should be

the patient and quality of care.

Don’t compromise your bottom line
for cents on the dollar — no matter
how hard you may be pushed.

James L. Comerci, M.D.

148 THE WEST VIRGINIA MEDICAL JOURNAL

Editorial

Managed care

These two words have always
managed to clank with doctors. What
do they think we have been doing
with care all these years? Care doesn’t
just happen. Someone has always
made it happen and that someone has
always been a doctor.

What the phrase managed care
really implies is that someone other
than a doctor should manage the care
or, at best, someone other than the
doctor ultimately to be responsible
should be the “manager.” Thus, Dr.
Soandso from Chicago, Boston or
Minneapolis can call you and begin
dictating what care your patient’s
insurance plan will pay for, even
though he or she has never seen,
touched or talked to this patient. If
you happen to be dealing with an
HMO, the call will usually be from
someone other than a doctor who, if
you demand it, will identify
themselves as a nurse. Of course, if
you protest about being told about
how to care for your patient,
invariably this individual will say you
may proceed as you wish, but that the
insurance company will not be paying
for it.

Seemingly overlooked is the fact
that not everything we do is of an
emergency nature. Since Hippocrates,
most of the things doctors have been
called upon to do for patients have
been interventions or procedures to
relieve discomfort, partially disabling
pain or other self-limited conditions.
Under “managed care,” all of these
tend to be looked at with a jaundiced
eye and discouraged in a variety of
ways.

In case it escapes your attention,
what is being questioned is not just

your judgement, but your integrity as
well. That insurance company and
that HMO do not consider you honest
enough to make decisions for your
patient. It’s a shame and a disgrace
that we have allowed this to happen
without some protest. If there is a
fault to be named, it is that we have
allowed, without loud protest, concern
for the integrity of an insurance
company’s financial balance sheet to
override concern for the integrity of
the physical and mental wellbeing of
our patients.

That wellbeing is the core of
concern of the doctor/patient
relationship touted since the days of
Hippocrates. Non-physicians have no
such concern. It is no real criticism of
an insurance company, or of any
profit-making commercial establishment
for that matter, to state that it has no
such concern. The responsibility of
profit-making enterprises generally
stops at a focused concern for their
balance sheet. They are supposed to
make money. Any other area of
concern or responsibility comes in a
distant second. This same level of
responsibility applies to any of their
employees, including those irritating
people making those phone calls.

Since there is no basis in ethical
principles and only the pragmatic
concern for making money, certain
problems arise in managing care for
HMOs and insurance companies, and
in obtaining care for the patients they
cover. Raises and promotions for
employees are generally based on
how well any given employee
advances the company’s goals.

Because of this fact, it is not
unreasonable to expect that

employees will act in their own self
interest, at least at times and some
more often than others.

This problem is particularly bad for
employees of self-funded companies
and those insurance companies that
contract out the job of managing care.
Such contracts are based on the
contractor’s capability of, or guarantee
of, reducing expected medical care
costs. For anyone at all familiar with
medical care, it takes little imagination
to conceive how, in the absence of
ethical, moral and legal constraints,
one might reduce any medical cost
figure by any suggested percentage or
dollar amount. Herein lies the danger.

Those in the business of “managed
care” care about dollars. They are
motivated by the need to save and
accumulate dollars. Pain, suffering,
misery, in a business sense, are words
lacking in any motivational quality. To
physicians, these words are a call to
action.

At this point, it seems that no matter
how trendy and politically correct it
might currently seem, doctors can do
nothing more than dislike and resist
“managed care.” We can thank Hillary
for a new appreciation of the depth
and meaning of this term. It took a
battalion of lawyers and 1,346 pages
of legalese to explain it all, but now it
seems pretty clear.

- Stephen D. Ward, M.D.

Editor

APRIL 1994, VOL. 90 149

In My Opinion

My answer, or don’t confuse me with the facts

In the debate over health care, it is vital that we stay
informed and that we counter emotional blathering with
facts. Here are my responses to the major arguments
offered by the radical reformers:

1 . Argument: AMA does not speak for most doctors.

After all, only 49% of doctors belong to AMA.

Reply: Yes, and President Clinton represents only

43% of the electorate.

2. Argument: Costs are “skyrocketing” and something

must be done.

Reply: According to the Bureau of Labor and

Statistics, medical inflation was 3.4% in
1993 — the lowest in 20 years. Among the
six most developed countries (U.S., U.K.,
France, Germany, Japan and Canada), the
U.S. ranked fifth out of six in medical
inflation over the last 20 years.

3. Argument: Managed care, including HMOs will
restrain the surge in medical costs.

Reply: The Congressional Budget Office has

concluded there is no evidence that
managed care can save money. The Health
Care Financing Administration (HCFA) has
studied Medicare recipients in HMOs and
concluded that patients spend 6% more for
HMO care than they do with straight
fee-for-service. Currently 25% of the insured
population is in an HMO and many more
are covered by managed care plans, yet
there has been no discernable effect
on overall medical costs.

4. Argument: We pay more for medical care than any
other country.

Reply: We have the best medical care in the

world and the best always costs more.
Foreigners do not come to the United
States to see how we make cars, but how
we practice medicine. The cheapest
treatment is not always the best. Aspirin
and crutches are cheaper than a hip
replacement. Other countries do not have
the burden of AIDS, gun-related violence,
drug addiction and teenage pregnancies
that we have.

5. Argument: There are 39 million Americans who do
not have insurance.

Reply: This figure includes individuals between

jobs, those who choose not to have
insurance, all those without health
insurance for any part of the year, so it is
much lower at certain times. All of these
people still get health care despite their
lack of insurance.

6 Argument:
Reply:

7 Argument:
Reply:

8 Argument:
Reply:

9 Argument:

10. Argument:
Reply:

1 1 Argument:
Reply:

Universal coverage is necessary to prevent
cost-shifting.

Studies of cost-shifting have consistently
shown that the cause is not the relatively
few uninsured patients presenting for care,
but Medicare and Medicaid failing to pay
the costs associated with care.

A single-payor system would be the most
efficient means of providing health care
and it would lower administrative costs.

A single-payor means the government
only. Government has not earned the trust
of the public with previous programs such
as Medicare, Medicaid, the VA, military
medicine and the U.S. Public Health
Service, all of which have promised more
than delivered.

Doctors are only a special interest group
out to protect their own turf.

In health care, there are no disinterested
parties. The government is the payor for
42% of current health care. Do you really
think they only talk to angels and have no
stake in the outcome?

What about poor old Sally Hardluck, who
developed breast cancer two weeks after
losing her job and now needs a bone
marrow transplant?

Let’s get away from ancedotes. If
ancedotes are persuasive, they would
prove that capitalism is no good. After all,
capitalism breeds bankruptcies, and I
might add, success.

The main causes of soaring costs are
greedy doctors, gouging drug companies
and profiteering hospitals.

The main cause of medical inflation is
advances in technology and the aging of
the population. Half of all hospitals had to
lay off staff last year, drug companies are
laying off thousands and drug inflation last
year was 3-1%.

Doctors do not like old people.

Doctors invented old people.

Wallace D. Johnson, M.D.
Beckley

SS.

150 THE WEST VIRGINIA MEDICAL JOURNAL

Our Readers Speak

More appropriate for the editorial page

A middle school West Virginia history teacher recently
asked his class, “Why is there so much poverty in West
Virginia?” His answer was “because we have too many
poor people.” Robert M. Frumkin, Ph.D., seemed to reach
the same conclusion in your February feature article,

“ Employment , Race and Poverty in West Virginia:
Implications for Practicing Physicians. ”

After an informative article with well-researched
demographics, the author concludes with an editorial
expressing his opinion in favor of abortions. He states that

abortions are “generally necessary” for unplanned
pregnancies. His answer for reducing the number of poor
African-Americans in West Virginia is to make sure they
don’t survive until birth. He goes further to tell us how
“physicians must respond.” His concluding comments
should have been on the editorial page rather than part of
a feature article in a scientific journal.

Hoyt J. Burdick, M.D., F.A.C.P., F.C.C.P.

Huntington

The Hospital Medical Staff Section 23rd Assembly Meeting

June 9-13, 1994 Chicago Marriott Hotel Chicago, Illinois

HMSS representatives will not want to miss this year’s AMA-HMSS Annual Assembly Meeting held
on June 9-13 in Chicago. Aside from the usual policy-related activities, representatives will have
an opportunity to dialogue with the AMA Board of Trustees, hear the latest news and information
from Washington, and learn the importance of and methods for physician involvement in health
system reform.

The Friday education program hosts an impressive panel of speakers. From their remarks,
representatives will learn: the impact of proposed legislation on the future practice of medicine;
the kinds of managed care entities most likely to thrive; the ways to cope with health care delivery
changes at the local level; the support needed to pass legislation on physician involvement in
health system reform; the steps for developing a physician-directed health delivery network or
plan; and the best methods for managing patient care and physician compensation in physician
health plans.

Involvement Assembly meeting is no exception. Now perhaps more than ever before, HMSS representatives

in need to be involved in shaping the nation's future health care system.

Health

System HMSS past actions have made a difference. The AMA has incorporated many issues advocated by

Reform HMSS in its new health system reform proposal for action and model legislation. Basically, the

draft bill:

• requires that health plans establish a medical staff structure with defined rights with regard
to the plan’s medical policy, utilization, quality and credentialing and management issues;

• expressly permits physicians to jointly present their views on any plan issue (without boycott
or strikes) to plan management for discussion and negotiation;

• directly aids physicians in the creation of their own plans or networks to compete with large
insurance companies;

• requires negotiation of new regulations with the profession before their announcement ; and

• expands the role and protection for the profession’s accreditation, standard setting and medical
society disciplinary functions.

Success will depend on unified physician support and action. Mark your calendar
and plan to attend!

FO, more information pioao. oaii American Medical Association

312 464-4754 or 464-4761 Physicians dedicated to the health of America

Interactive

Dialogue

with

AMA Board
of Trustees

APRIL 1994, VOL. 90 151

At Annual Meeting

Noted vascular surgeon

to deliver Harris Address

Dr. Bergan

John J. Bergan, M.D., F.A.C.S.,

HON., F.R.C.S.CENG.), a clinical
professor of surgery at the University
of California in San Diego, will present
this year’s Thomas L. Harris Address
on Friday, August 19 during the First
Session of the WVSMA House of
Delegates at the WVSMA’s 127th
Annual Meeting at The Greenbrier in
White Sulphur Springs. His topic will
be “Current Management of Extracranial
Cerebral Vascular Disease.”

Dr. Bergan received his medical
degree from the Indiana University
School of Medicine in 1954, where he
also completed his internship. He was
influenced by the vascular surgery of
Dr. Harris Shumacker during his
internship and decided to complete
his residency at the Northwestern
University Medical School under the
guidance of Dr. Walter Maddock, one
of the founders of the Society for
Vascular Surgery. Upon finishing his
residency in 1959, Dr. Bergan was
appointed to the faculty of
Northwestern University.

Early research interests in
pancreatitis quickly led Dr. Bergan to
explorations of vascular injury in this
condition and then to the study of
intestinal ischemia. This area of
research continued to be Dr. Bergan’s
major interest, but he also began
studying renal transplantation,
pancreatic transplantation, and liver
preservation. His activities in
transplantation led to his appointments
as chief of transplantation at
Northwestern University Medical
School in 1969 and as director of the
Organ Transplant Registry at the
American College of Surgeons in 1970.

Since 1973, Dr. Bergan has been
devoting his time to vascular surgery
exclusively, describing the selective
portosystemic shunt, and developing
the non-invasive laboratory at
Northwestern University Medical
School with Dr. Yao. His interests in
innovations in presentation led to the
breakfast sessions held annually at the
meetings of the Society for Vascular
Surgery and the International Society

for Cardiovascular Surgery, North
American Chapter. Dr. Bergan was
also instrumental in the formation of
the Midwestern Vascular Surgery
Society and the American Venous
Forum.

In 1989, Dr. Bergan was named to
his current position as a clinical
professor of surgery at the University
of California at San Diego. That same
year, he also assumed his other two
current posts as a clinical professor of
surgery at the Uniformed Services
University of the Health Sciences in
Washington, D.C., and as an academic
consultant in vascular surgery at
Balboa Naval Hospital in San Diego.

president of the Society for Vascular
Surgery, the European-American
Venous Symposium, the American
Venous Forum, the International
Association of Vascular Surgeons, the
Chicago Surgical Society, and the Gulf
Coast Vascular Society.

Dr. Bergan is a member of several
editorial boards including Surgery,
Journal of Vascular Surgery, Journal of
Cardiovascular Surgery>, the Annals of
Vascular Singety, British Journal of
Surgery’, Phlebology, and is the
founder/editor of Postgraduate
Vascular Suigery and International
Vascular Surgery. He is the co-editor
of a number of textbooks of vascular
surgery, and is the former editor of
the annual Year Book of Vascular
Surgery.

Information about other speakers at
this year’s WVSMA Annual Meeting
will be published in upcoming issues
of th e Journal and a registration form
appears on page 155- For more
details, contact Nancie Diwens at
(304) 925-0342.

152 THE WEST VIRGINIA MEDICAL JOURNAL

Legislative

Reception

Director of Government Relations Winnie Morano speaks
with Sonia Daugherty of PEIA and Delegate Bonnie Brown
about pending legislation.

Charleston lawyer Jon Amores (right), a candidate for the
House of Delegates, talks about his campaign with his
mother. Dr. Diana Amores, Dr. Raymond Rushden, and
Troy Hendricks, a former member of the House of
Delegates.

At the WVSMA’s Legislative Reception at the Charleston Marriott, Delegate
Karen Facemeyer discusses health care issues with Dr. Jeff Stead and Delegate
Robert Pulliam, M.D., who is Council chairman for the WVSMA. Conversing to
their right are Dr. Harry Shannon and Delegate Bob Ashley.

Delegates Bob Ashley (left) and Nancy Kessel (third from left) who is also a
member of the WVSMA Alliance, were pleased to visit with Pacita Salon, past
president of the WVSMA Alliance; Judy Bofill, vice president of the WVSMA
Alliance; Dr. Miraflor Khorshad; and Dr. Rano Bofill.

Members of the Office Managers Association, Gary Linkous of Princeton
Orthopedic Center; Carol Simpson of the office of Dr. Kenneth Clark; Teresa
Painter of Infectious Disease Consultants; Dianna Yerrid of Medical Imaging
Services, Inc.; and Sue Simpson of the office of Drs. Pearcy, Busch and Hill;
take a break from mingling to enjoy the buffet. The members of the Office
Managers Association are very important in helping the WVSMA in its
legislative efforts.

APRIL 1994, VOL. 90 153

WVSMA to sponsor CME workshop with CAMC, MU, WVU

At the request of many accredited
health care providers of CME, the
West Virginia State Medical
Association's Committee for Medical
Education, in conjunction with the
Charleston Area Medical Center,
Marshall University and West Virginia
University, is conducting a one-day
workshop entitled "CME: Paradigms
of the Future.”

Set for Thursday, May 19 at the
Robert C. Byrd Health Sciences Center
of WVU, Charleston Division, this
workshop is designed for directors of
medical education, medical education
coordinators and all others involved
in the planning, development,
implementation and evaluation of
CME activities. It will also prepare
individuals interested in obtaining
accreditation for sponsorship of CME
activities.

After a welcome at 9:30 a.m. by Dr.
John W. Traubert, chairman of the
WVSMA's Committee for Medical
Education, and WVSMA President Dr.
James L. Comerci, the workshop will
begin with a presentation on “ The
History and Future of CME,” by
Frances Maitland, executive director
of the Alliance for Continuing Medical
Education. The Alliance is an
international professional association
with over 1,400 members, concerned
exclusively with continuing medical
education.

Ms. Maitland was formerly the
assistant secretary of the Accreditation
Council for Continuing Medical
Education. She served in this capacity
since the inception of the ACCME on
January 1, 1981, and as assistant

secretary of the former Liaison
Committee on Continuing Medical
Education since 1978. A graduate of
the University of Michigan, Ms.
Maitland has also held positions with
the Council of Medical Specialty
Societies and the American Academy
of Orthopaedic Surgeons.

Following Ms. Maitland's lecture,
Michael I. Gannon, associate director of
CME for the AMA, will discuss
“Category 1 and 2 - Differences and
Reporting Mechanisms.” Mr. Gannon
has been involved in CME at the AMA
for the past 15 years.

After a break, the workshop will
continue with a lecture by David F.
Lichtenauer, B.S., M.A., a CME
consultant from Cincinnati. Mr.
Lichtenauer will discuss “ How FDA
Policy Affects CME Resources. ”

An employee of the Upjohn
Company for the past 30 years, Mr.
Lichtenaur served as Upjohn’s liaison
with many of the national associations
in medical education as part of the
Medical Sciences Liaison/Education
Unit. Since October 1. 1992, he has
been the medical relations manager of
national medical organizations for
Upjohn.

Mr. Lichtenauer is a member of the
Alliance for Continuing Medical
Education's (ACME) Board of Directors
and serves on the Industry/CME
Collaboration Task Force that produced
the revised ACCME Standards for
Commercial Support of CME. In
September 1993, the ACME appointed
him to their External Monitoring
Committee, which evaluates, suggests,
implements and addresses complaint

procedures relative to the random
monitoring procedures for ACME at
national and state levels.

Following Mr. Lichtenauer's lecture,
a luncheon will take place at noon.
The speaker for this luncheon will be
WVSMA Executive Director George
Rider, who will discuss “The Medical
Practice Act.” The afternoon sessions
will then be devoted to topics dealing
with the accreditation process and
program approval in West Virginia.
The format will be an informal one
with active audience participation.

The first afternoon session will
feature a demonstration of MDTV/
Medline, which will be conducted by
Dr. James Brick and Dr. Joseph Skaggs.
Next, Dr. John Traubert and WVSMA
Associate Executive Director Nancie
Diwens will discuss the factors needed
for obtaining CME accreditation.

The sessions will continue with a
panel on “ Approving Programs -
Essentials and Standards” with Frances
Maitland, David Bailey of MU's CME
Program, Robin Rector, director of
continuing education and conference
services for CAMC, and Kari Long,
program director of CME and rural
services for the Robert C. Byrd Health
Sciences Center, Morgantown. The last
session will focus on “ What the
Surveyor Looks For,” with Dr. Traubert,
WVSMA Vice President Dr. James
Helsley, and Dr. Comerci. The meeting
will conclude with a question and
answer session with all of the day's
speakers.

The registration fomi is printed below
and you may contact Nancie Diwens at
(304) 925-0342 for more details.

Registration Form

Name

Title

Organization

Phone

Address

City State Zip Code

Registration fee: $1 25

Physician members: $75

Payment by: — Check — Visa — MasterCard

Card Number

Expiration Date

Signature

If paying by check, please send registration form
and check to:

West Virginia State Medical Association

P.0. Box4106
Charleston, WV 25364
(304)9250342

154 THE WEST VIRGINIA MEDICAL JOURNAL

The West Virginia State Medical Association’ s

August 17-20, 1994

The Greenbrier

White Sulphur Springs, West Virginia

V Sign Up NOW!

Please be sure to make hotel reservations in advance by calling 1-800-624-6070. The Greenbrier
will fill up quickly because the State Fair will be going on during the same week.

1994 Annual Meeting

Name

Address

City State Zip Code

Specialty

Payment by: Check Visa MasterCard

Card Number

Expiration Date

Conference Cost:

WVSMA member

$125 .

non-member

$175

Additional:

Thursday, Aug. 18
Learn and Learn

member/non-member

$40

(CME Credit)

spouse/student

$25

Friday, Aug. 19
Lunch and Learn
(CME Credit)

member/ non-member

$40

spouse/ student

$25

TOTAL:

Signature

If paying by check, please send registration form and check to:
West Virginia State Medical Association
P.O. Box 4106, Charleston, WV 25364

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Robert C Byrd Health Sciences
Center of WVU - Charleston

April 21

(Teleconference) “Childbirth
Education Update,” Paula Vasale,
R.N.C., B.S.N., C.E.S.

May 5

(Teleconference) “Respiratory
Distress in the Newborn,” Stefan R.
Maxwell, M.D.

May 11-12

(Seminar) “3rd Annual Issues in
Perinatal Health Care”

May 17

(Seminar) “Management of a
Congenital Neck Mass” (sponsored
by The Eye and Ear Clinic of
Charleston and the Dept, of Surgery),
R. Austin Wallace, M.D., F.A.C.S.

May 19

(Teleconference) “Blood Borne
Pathogens: The Health Care Providers’
Risk,” Elizabeth A. Funk, M.D.

June 2

(Seminar) “ABCs of Caring for HIV-
Infected Patients,” Elizabeth A. Funk,
M.D.

June 16

(Seminar) “Pediatric Update,” Naser
Tolaymat, M.D.

June 21

(Seminar) “Management of Salivary
Gland Disorders,” (sponsored by The
Eye and Ear Clinic of Charleston and
the Dept, of Surgery), Robert E.
Pollard, M.D.

Robert C Byrd Health Sciences
Center of WVU - Morgantown

April 22-24

“West Virginia State Radiological
Society Spring Meeting: Breast Care
Update 1994 (sponsored by the
WVU Dept, of Radiology and the
West Virginia State Radiological
Society), Lakeview Resort and
Conference Center, Morgantown

April 30

“Current Concepts in Cancer Care for
the Non-Oncologist” (co-sponsored
with Monongalia General Hospital),
Lakeview Resort and Conference
Center, Morgantown

May 1-4

“Wellness Conference,” Lakeview
Resort and Conference Center,
Morgantown

May 20

“Second Annual Stephen C. Rector
Visiting Lectureship in Emergency
Medicine” (sponsored by the WVU
Dept, of Emergency Medicine)

May 20 21

“5th Annual Ophthalmology Alumni
Weekend” (sponsored by the WVU
Dept, of Ophthalmology)

May 27 29

“Anesthesia Update” (sponsored by
tire WVU Dept, of Anesthesiology and
the West Virginia and Virginia State
Societies of Anesthesiology), The
Greenbrier, White Sulphur Springs

June 2-3

“The Spiritual Dimension of Illness,
Suffering and Dying (sponsored by
the WVU Center for Health Ethics
and Law)

West Virginia State Medical
Association - Charleston

May 19

“CME Workshop: Paradigms of the
Future,” Robert C. Byrd Health
Sciences Center of WVU, Charleston

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Gassaway □ Braxton County Memorial
Hospital, April 27, 6:30 p.m.,
“Indications and Risks of Blood
Transfusions,” Mary S. Taylor, M.D.

Oak Hill □ Plateau Medical Center,
April 26, 6:30 p.m., “Pediatric
Trauma,” A. Margarita Torres, M.D.

Parkersburg ★ Camden-Clark Memorial
Hospital, April 21, 7 a.m., TBA,

N. Andrew Vaughan, M.D.

Point Pleasant □ Pleasant Valley
Hospital, April 28, noon, “New
Technologies in High Risk
Obstetrics,” Norman Duerbeck, M.D.

Williamson □ Williamson Appalachian
Regional Hospital, April 28, 5:30 p.m.,
“Evaluation of Arthritic Patients,”
Michael Istfan, M.D.

WHEN YOU
CANT BREATHE
NOTHING ELSE
MATTERS®

For information about
lung disease such as
asthma, tuberculosis, and
emphysema, call
1-800-LUNG-USA

^ AMERICAN LUNG ASSOCIATION.

156 THE WEST VIRGINIA MEDICAL JOURNAL

leeS Poetry Corner y

May

1- 7-American Society of Neuroradiology,
Nashville, Tenn.

2- 5-American Pediatric Society, Seattle

7- 8-American Laryngological, Rhinological
and Otological Society, Palm Beach, Fla.

8- 11— American College of Mohs
Micrographic Surgery and Cutaneous
Oncology, San Diego

8- 13— American Society of Colon and Rectal
Surgeons, Orlando, Fla.

9- 12-American College of Obstetricians and
Gynecologists, Orlando, Fla.

11-14-1 5th Annual Meeting of the North
American Society of Pacing and
Electrophysiology, Nashville, Tenn.

11- 15-American Society for Dermatologic
Surgery, San Diego

12- 13-Building Blocks of Health Care
Reform: Health Information and Quality
Assessment (sponsored by AMPRA,
Consumer Coalition, NAHDO and NBCH),
Washington, D.C.

12- 17— American Trauma Society, McLean, Va.

13- 14— Topics in Radiology (sponsored by
the University of Pittsburgh School of
Medicine), Pittsburgh
13-15-Rheumatology and Allergy Update:
1994 (sponsored by Ohio State University),
Mt. Sterling, Ohio

13- 15-The Managed Care Revolution:
Winning Strategies for Internists (sponsored
by the American Society of Internal Medicine),
Boston

14- 16— tth Annual Meeting of the American
College of Radiation Oncology, Washington,
D.C.

14- 19-American Urological Association, San
Francisco

15- 18-American Gastroenterological
Association, New Orleans

18-20-47th .Annual National Conference of
the President’s Committee on Employment
of People With Disabilities, Atlanta

20- 21— Neurology for the Non-Neurologists
(sponsored by Ohio State University),
Columbus

21— Fifth Annual Rush Symposium on
Transplantation, Chicago
21-25-American Psychiatric Association,
Philadelphia

25-28-National Rural Health Association's
17th Annual National Conference, San
Francisco

Beauty

Beauty is in the eye of the beholder,

A person who was very wise once said,

But beauty comes in sound as well as sight,

So beauty also is in the ear of those who hear:

The sight of a bluebird in graceful flight

Against a backdrop of sun-filled summer skv;

The sound of its song earned on a gentle breeze ;

The beauty of the ever-changing trees
As seen on autumn days with multi-colored
Leaves of yellow, orange, red and gold;

Seeing newly fallen snow on winter days so cold;

Budding trees in spring, and flowers' early bloom,
Dispelling certain feelings which one has

Because of winter days so drab; so full of gloom.
Music played by symphonies or sung by lovely voice;

Or choir singing choral works may be your choice.
Beauty, then, is where and how one may perceive,

And comes free of cost to those who will receive.

E. Leon Linger, M.D.

Sweetness

Her day rose was much sweet
Her sweetness was most love
Her loveliness was all white
Her whiteness was like a dove.

Romeo Y. Lim, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward, M.D.,
Editor, West Virginia Medical Journal P. O. Box 4106, Charleston, WV 25364.

For More Information . . .

Contact the Journal at (304) 925-0342.

APRIL 1994, VOL. 90 157

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

Bureau recruiting
professionals for early
intervention program

The Bureau of Public Health is
expanding its family-centered,
interdisciplinary services for infants
and toddlers with developmental
delays or medical conditions that put
them at risk for such delays. These
children, from birth through age 2,
and their families are eligible for free,
federally-mandated Early Intervention
Services through the Bureau’s Office
of Maternal and Child Health (OMCH).

Due to the state's shortage of
physical therapists, occupational
therapists, speech therapists and other
professionals trained to work with
special needs children, the Bureau’s
Office of Community and Rural
Health Services is working with the
OMCH and the Marshall University
School of Medicine to develop a new
recruitment program to encourage
individuals to enter these fields. This
new effort, the Recruitment for Early
Intervention Project (REIP), will
operate on three levels.

The first two levels will only be
offered to West Virginia residents in
order to recruit individuals who are
most likely to remain in the state. Both
the loan repayment program and the
scholarship program will require the
students to fulfill an employment
contract at a community-based agency
that offers early intervention services
through the OMCH upon completion
of their training. The third category will
consist of salary supplements or
incentives to recruit people already in
these specialties to join West Virginia’s
Early Intervention Program.

Another aspect of the project will be
to work with West Virginia colleges
and universities to develop or expand
existing training programs. Currently,
the number of physical therapy and
speech therapy programs available is
limited, and there are no occupational
therapy programs offered in the state.

Staff are now working with students
and clinicians around the state to
communicate the needs of the Early
Intervention Program and the
opportunities available. Recruiting is
scheduled to begin this fall.

For more details, call Brian
Loshbough at (304) 558-4007.

Study investigating
Lyme Disease cases

State and federal public health
officials have began an investigation
into the unusually high number of
Lyme disease cases reported over the
past two years in Greenbrier and
Raleigh counties. Staff from the
Bureau of Public Health and the U.S.
Centers for Disease Control and
Prevention (CDC) are teaming up to
conduct a health study of 52 state
residents who, according to physician
reports, were either diagnosed with or
suspected of having Lyme disease in
1992 or 1993.

“West Virginia hasn’t been
considered a high incidence region for
Lyme disease, and we haven’t had
more than 50 cases reported statewide
in any given year,” explained State
Health Commissioner William T.

Wallace Jr., M.D., M.P.H. “When it
came to our attention last summer that
such a large number of cases were
being diagnosed in one particular part
of the state, we began the process
that’s led to this study. We want to
determine if a health problem does
exist, and if so, what to do about it."

Public health workers began
contacting the 52 patients in March,
and those who agree to take part in
the study will be interviewed to learn
more about when their symptoms
were first noticed, what sort of medical
examinations and testing they have
undergone, and what medications
have been prescribed for them. Blood
samples will be taken from them for
further testing, and each participant
will also be asked to have a household
member or a neighborhood friend
serve in a control group. These
individuals will be near the same age
as the patient, but will not have been
diagnosed with the disease. Studying
both the patients and the control
group may help indentify how people

are contracting the disease, which is
often difficult to diagnose because
blood tests can't always correctly
identify it.

Results of the study are expected
later this spring and more information
can be obtained by phoning Loretta
Haddy at (304) 558-5358.

Mammography sites
prepare for new regs

Staff from the Bureau’s Office of
Health Facility Licensure and
Certification (OHFLAC) and the Office
of Environmental Health Services
(OEHS) have been working with
personnel at mammography sites
around the state to ensure compliance
with current and upcoming federal
regulations established in the Medicare
Screening Mammography Certification
program.

A total of 66 hospital-based and
free-standing mammography service
suppliers are enrolled in the program,
which grants certification by the HCFA
for Medicare-funded procedures. By
October 1, each facility will undergo at
least one on-site inspection by
OHFLAC and OEHS staff.

In October 1994, regulations
implementing the Mammography
Quality Standards Act of 1992 (MSQA)
become effective. Unlike the current
HCFA program, these regulations will
apply to all mammography facilities,
whether their services are screening or
diagnostic, and responsibility for
compliance will not be limited to
facilities participating in Medicare. In
order to meet the provisions of MSQA,
facilities must meet federal quality
standards and certification standards,
and either be accredited by, or apply
for accreditation by an approved
accredited body.

Also, MSQA will be administered by
the FDA, rather than by HCFA. Once
the new program is in place, there
may be no further need for HCFA to
conduct the inspections that are
presently occurring, depending on the
manner in which FDA elects to
administer the program.

For more information, contact the
OHFLAC at (304) 558-0050 or the
OEHS at (304) 558-2981.

158 THE WEST VIRGINIA MEDICAL JOURNAL

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Join the team of business leaders who are helping their employees learn how to prevent HIV and AIDS.

Call the CDC Business Responds to AIDS Program at 1-800-458-5231.

Well send you materials and give you all the help you need.

A message from the U.S DEPARTMENT OF HEALTH & HUMAN SERVICES, Public Health Seivice, Centers for Disease Control and Prevention.

Robert C. Byrd

HEALTH SCIENCES CENTER

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Grads choose family
practice, primary care

More than 60 percent of this year’s
graduating class from the School of
Medicine have been accepted into
residency programs in primary care.
Nearly half the class will train as
family physicians or in general internal
medicine, and nearly 56 percent will
stay in the state for residency training.

“This is the highest number of
students choosing primary care
residencies in the history of the four-
year medical school,” said Dr. John
Traubert, associate dean for student and
curricular affairs. “Of the 77 students in
the Class of ’94, 18 (24%) will enter
family medicine residencies and an
equal number will enter residency
programs in general internal medicine.

A total of 47 class members will be in
primary care programs, including
pediatrics, medicine/pediatrics and
obstetrics/gynecology,” he added.

“Our students have heard and
understood the debate on the future
of health care,” said Dr. Robert
D'Alessandri, vice president for health
sciences and dean of the School of
Medicine. “It’s clear that, to meet the
needs of people in the next few
decades, we will have to train more,
and better, primary care physicians.
Many members of the Class of ’94 are
going to be among them.

“We will also continue to need
surgeons, radiologists, anesthesiologists
and other specialists and I’m certain
that this class will also produce some
outstanding physicians in these fields."

Applications for Med
School at all time high

A record number of 1,917 students
have applied to the School of Medicine
for the year beginning this fall.

Of these applicants, 245 are West
Virginia residents, and about 90
percent of this entering class will be
selected from among these individuals.

Ducatman receives
authorship award

Dr. Alan Ducatman,
professor and director
of the Institute of
Occupational and
Environmental
Health, has been
selected as this year's
recipient of the
Adolph G. Kammer
Merit in Authorship
Ducatman Award by the

American College of Occupational and
Environmental Medicine (ACOEM).

ACOEM is presenting this award to
Dr. Ducatman in recognition of his
article “ The Occupational Physician
and Environmental Medicine ,” which
was published in the March issue of
the Journal of Occupational Medicine.

Dr. Ducatman will receive the award
at the annual business meeting of the
ACOEM on April 21 in Chicago.

MDTV, MARS create
awareness program

Mountaineer Doctor Television
(MDTV) and the Medical Access &
Referral System (MARS) have started a
program to increase awareness of the
benefits of MDTV’s audio and video
communications link between rural
hospitals and the HSC.

When WVU physicians receive
referrals from MARS, they will be told
when the physician or health care
provider making the call is at an
MDTV site. This will serve as a
reminder to WVU physicians that they
can take the process one step further
and actually see the patient being
discussed by the doctor. The WVU
physician and the referring physician
can then have a video consultation or
schedule a time convenient for all
parties through the MARS office.

In addition to the campus sites in
Morgantown and Charleston, MDTV
has sites at Wetzel County Hospital,
New Martinsville; Grant Memorial
Hospital, Petersburg; Davis Memorial
Hospital, Elkins; St. Joseph’s Hospital,
Buckhannon; and Boone Memorial
Hospital, Madison.

Prostate Health
Center established

WVU has established the state's first
Prostate Health Center to promote and
coordinate education and infonnation
on prostate diseases for the public and
for health care professionals.

Dr. Unyime Nseyo, associate
professor of urology, is the center's
director, and Dr. Stanley Kandzari,
vice-chair of the Department of
Urology, will be co-director. The
center is funded by a grant from the
Human Health Division of Merck
Pharmaceuticals in Dublin, Ohio.

For more details, call the Prostate
Health Center at (304) 293-1429.

Two professors elected
to national posts

Mary Davis, Ph.D., and Robert
Stizel, Ph D., both professors in the
Department of Pharmacology and
Toxicology, have been elected to
national offices.

Dr. Davis will begin a three-year
term as treasurer of the Society of
Toxicology in May. In addition to
attending to the society's budget
matters, Dr. Davis will be a trustee for
the Toxicology Education Foundation.

Dr. Stitzel, who is also special
assistant to the provost, is in the first
year of a three-year tenn as secretary/
treasurer of the American Society for
Pharmacology and Experimental
Therapeutics.

Two Birthscore posters
accepted for meeting

Two posters showing results from
the West Virginia Statewide Birthscore
System have been accepted by the
International Society on Infant Studies
for its conference in Paris, June 2-5.

The posters were submitted by Dr.
Chet Johnson, associate professor of
pediatrics and director of the W.G.
Klingberg Child Development Center;
RN Lois Morgan, project manager of the
West Virginia Statewide Birthscore
Project; and Chris Britton, Birthscore
technician.

Ducatman

160 THE WEST VIRGINIA MEDICAL JOURNAL

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and the American Board of Electro-Diagnostic Medicine.

Specialist in Electromyography and Nerve Conduction Studies

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For appointment, call: (304) 344-5153

Marshall University
School of Medicine

Compiled from material furnished by the
Office of Un iversity Relations, Marshall
Un iversity, Hu ntington .

MU expands RuralNet
through worldwide
Internet program

Marshall has developed a powerful
computer resource that saves users
worldwide from having to explore
every inch of the “information
superhighway” when they want
material on rural health.

Six years ago, Marshall created
RuralNet to give medical students the
informational resources they need
during their nine-month rural
placements. With the advent of the
statewide Kellogg and Rural Health
Initiative programs, Marshall
expanded the network to serve all
health professions students at more
than 130 sites. In March, Marshall
made the resource available worldwide
through Internet, a global aggregate of
computer networks which links more
than 1 1 ,000 subnetworks and more
than 20 million users.

Once students or Internet users link
into RuralNet, a simple menu system
whisks them to exhaustive data
collections in the blink of a cursor.
Marshall computer experts extensively
searched the Internet for collections
relevant to rural health, then used a
search and retrieve utility known as
“Gopher” to automate the complex
routing commands necessary to reach
those collections.

The RuralNet Gopher groups
resources into categories ranging from
clinical resources to health science
libraries to health care policy, reform
and management. From there, users
can reach hundreds of informational
sources such as the Rural Information
Center Health Service at the federal
Office of Rural Health Policy and the
CancerNet PDQ system of the
National Cancer Institute.

Ironically, those technological
capabilities so far have caused less of
a stir than the infrastructure Marshall
first developed to, as one staff member
put it, “pave the information dirt path.”

Medical educators around the nation
are requesting information about
Marshall’s system which allows
students at remote sites to do Medline
searches, check for drug interactions,
send messages, and tap into worldwide
information sources.

“We’ve concentrated so hard on
getting these resources into the hands
of students and rural communities that
we only recently realized that other
schools are not nearly this far
advanced in rural access,” said Jan I.
Fox, chair of the Department of
Academic Computing.

Indeed, just four days after
computer educator Michael McCarthy
first mentioned the program on the
Internet, an official of the American
Public Health Association was asking
whether Marshall would demonstrate
RuralNet at this fall’s APFLA meeting.
Other institutions requesting
information include the University of
North Carolina, Southern Illinois
LTniversity, Tulane, Yale and Harvard.

Internet users can connect to
RuralNet by gophering to
ruralnet.mu.wvnet.edu on port 70.

Alumnus featured in
Wall Street Journal

Dr. John Hahn, a Marshall alumnus,
recently made national headlines in a
front-page Wall Street Journal story,

“ Washington Debates Health Care for
All; Dr. Hahn Delivers, ’’which profiles
his obstetrics practice in rural West
Virginia.

The rural area Dr. Hahn serves is
located, reporter Alecia Swasy wrote,
“about 180 miles — and degrees —
from Washington.” Based at Grant
Memorial Hospital in Petersburg, Dr.
Hahn cares for mothers and infants
from five rural counties. Part of that
care is provided through three
regional clinics he established with his
brother, Jerry, a fellow MU alumnus
specializing in family practice and
dermatology.

The brothers grew up in the town
of Wardensville and drew inspiration
from the local physician, J.D. Mathias,
John Hahn told the Wall Street Journal.
He added that his desire to return to
the area played a significant role in
his choice of specialty: with obstetrics,

MARSHALIMDNIVERSITY

he could almost assuredly get a nearby
assignment in fulfilling his obligation
to the National Health Service Corps.

Dr. Hahn is not new to the national
spotlight; the ABC newsmagazine
“20/20” featured him in a segment in
the late 1980s.

Mufson receives
Laureate Award

Dr. Maurice A. Mufson has received
the Laureate Award from the West
Virginia Chapter of the American
College of Physicians.

This award, according to the ACP,
“honors those Fellows of the American
College of Physicians who have
demonstrated by their example and
conduct an abiding commitment to
excellence in medical care, education,
or research, and in service to their
community, their Chapter, and the
American College of Physicians.”

Elected to Fellowship in the
American College of Physicians in
1973, Dr. Mufson has been very active
on the chapter level. He has served as
chairman of the Associates’ Program
Committee for the last four years and
is considered largely responsible for
its success. The award recognizes Dr.
Mufson’s contributions to developing
the Associates’ Program, as well as his
achievements in teaching and research.

Two Stanford
professors to address
graduating seniors

Two native West Virginian physicians
who have earned international
reputations in their fields will present
the ceremonial Last Lecture and the
Investiture address to graduating seniors.

Dr. Mary Lake Polan, chair of
Obstetrics and Gynecology at Stanford
University, will present the Last
Lecture at 8 p.m. on Thursday, May 5,
at the Huntington Museum of Art. The
Wayne County native will speak on
“Ihe Future of Women 's Health. ”

Logan native Dr. Joseph McGuire,
professor of dermatology and
pediatrics at Stanford, will address
seniors at the Investiture ceremony on
May 6 at Marshall’s Fine and
Performing Arts Center.

162 THE WEST VIRGINIA MEDICAL JOURNAL

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Alliance

News

AMPAC Campaign School a valuable experience!

I was warned! Dr. Robert Pulliam had told me the AMPAC Campaign Management School was an intense and
exhausting experience, but since he is one of my husband's partners, I figured he was kidding me or
exaggerating. But - - he wasn't!!!

Never before had 1 learned so much in such a short time. The school lasted one week and our days were
filled with outstanding lectures on these five main topics:

1. Campaign Groundwork - Strategy, Planning, Theme and Management

2. Research - Targeting, Polling, Opposition and Candidate Research

3. Fundraising and Budgeting

4. Communicating Messages - Advertising, Earned Media Coverage and Field Operations

5. Scheduling and Management Decision Making

A total of 32 adults, ranging in age from about 27 years old to 60 years old, attended the school. Several
were physicians, but the majority were the spouses of physicians. We were divided into four groups and after
our lectures were over at 5 p.m., we had to work on our own campaigns. First, we had to determine who
would be our candidate, and then we proceeded with selecting our manager and developing campaign
strategy.

Our planning sessions would last long into the night. Even though I would usually say goodnight at about
1 a.m., other members of my group would continue working until about 3 a m. Campaign school was a big
game, but everyone was very competitive and took it seriously.

The quality of the people attending this school was outstanding. Many had very strong personalities, but we
all possessed fine social skills which made it easy to interact. Most of the time we got along very well, except
some of us were not so tactful and charming when we became sleep deprived.

The instructors were professionals with extensive experience in Washington, D.C., and throughout the
country. They were experts to say the least - - very intelligent, funny and tough.

At the end of the week, the leaders of the school rated us on our behavior and interaction as a group, and
also how well we organized our campaigns. It was a great study in human dynamics. The candidate for my
group did not win because we didn't have everything in written detail. Although we had a fine presentation,
you couldn't bluff your way with these judges!

The candidate who did win was Jon Amores, the son of Drs. Diana and Tino Amores. Jon ran a great
campaign and his people did an outstanding job of detailing every aspect. As most of you know, Jon is a
candidate in Charleston for the House of Delegates. I'M SURE HE WILL WIN!!

The AMPAC Campaign Management School must be one of the best in the country. It taught me just how
much is involved in successfully running for office. The reality is - - you need many people to help you, a
substantial amount of money and total commitment.

I can't stress enough just how valuable an experience I think attending this school would be for any
physician or Alliance member. Not only do you gain an inside look at the world of politics, you learn how to
effectively campaign for candidates - - a critical lesson in medicine today.

Carole Scaring

WVSMA Alliance President

164 THE WEST VIRGINIA MEDICAL JOURNAL

West Virginia State
Medical Association
Alliance ^ — —

"Physicians' Spouses Dedicated To The Health Of West Virginia "
Who we are

The West Virginia State Medical Association Alliance is a volunteer organization of physician, resident and
medical student spouses. Also, retired and honorary members are actively involved in our organization. We
are over 700 members strong, including members-at-large and 1 5 county/region alliance chapters. With each
new member, we improve as an organization as the membership chain is lengthened and strengthened for the
good of medicine. We are a part of a federated system of medicine with our national office, the American
Medical Association Alliance Inc., in Chicago.

Our purpose

The WVSMAA was designed to assist in those programs of the West Virginia State Medical Association
that improve the health and quality of life for people, to uphold the programs of the AMA Alliance, to promote
health education, to encourage participation of volunteers in activities that meet health needs and to support
health-related, charitable endeavors.

Join Us Today!

West Virginia State Medical Association Alliance
Membership Application

Name

Spouse's name

Telenhone

Mailing Address

City

Zip

County

Dues enclosed

($25 National,

$18 State - Total = $43)

Return to: WVSMAA, P.O. Box 4106, Charleston, WV 25364, or for more information call 304/925-0342.

New Members WESPAC Members

We would like to welcome these
18 new members to the WVSMA:

Haleem Rasool, MD
Box 1858

Oceana, WV 24870

Gene Turner, MD
P.O. Box 99
Oak Hill, WV 25901

James C. McGhee, MD
P.O. Box 3086
Shepherdstown, WV 25443

Jose Chavez, MD
4505 Noyes Avenue
Charleston, WV 25304

Robert E. Pollard, MD
1306 Kanawha Blvd E.

Charleston, WV 25531

Elizabeth Hynes, MD
114 North Elm Street
Moorefield, WV 26836

David Ghaphery, MD
601 National Road
Wheeling, WV 26003

Raymond Coombe, MD
#10 Shannon Place
Charleston, WV 25314

Arturo Roa, MD
#3 Stonecrest Drive
Huntington, WV 25701

Richard Gobao, MD
300 Wedgewood Drive
Morgantown, WV 26505

James E. Adisey, MD
1325 Locust Avenue
Fairmont, WV 26554

John Walden, MD
1801 6th Avenue
Huntington, WV 25701

Mohammad Yousaf, MD
400 Division Street, Suite 6
Charleston, WV 25309

Dominick Zito, MD
5 Erwin Lane
Fairmont, WV 26554

Colin Iosso, MD
2010 Oates Drive
Martinsburg, WV 25401

Frederick Armbrust, MD
415 Morris Street, Suite 400
Charleston, WV 25301

Philip Light, MD

200 Maplewood Avenue

Ronceverte, WV 24970

Diego Gomez, MD
200 Maplewood Avenue
Ronceverte, WV 24970

We would like to thank the following

Monongalia

physicians and Alliance members for
their contributions to WESPAC:

Roger Abrahams

Physicians

Ohio

Terry A. Athari

A Dollar A Dav Club

Raleigh

"■Designates more than $365 in

Lewis Gravely

contributions

Narendrakumar Patel
Raquel S. Israel

Cabell

Rodger Blake

Tug Valley

*Kyle R. Hegg

Rao Vempaty

Rocco Morabito

Sustainer Members

Fayette

Miraflor Khorshad

Cabell

S. Kenneth Wolfe

Harrison

*Carlos Naranjo

Eastern Panhandle

David Waxman

Edward Pinney

Kanawha

Samuel Davis

Brad Cohen

Michael Kelly

Ujjal Sandhu

Lewis H. McConnell
Samuel Strickland

L. Blair Thrush Jr.

Marion

Monongalia

Sitha Katragadda

Paul Malone
Matt Midcap

Mason

Stephen Wetmore

Young I. Choi

Ohio

Monongalia

Vincente P. Almario Jr.
Michael Blatt

David Myerberg

Alfred Ghaphery

Ohio

Barton Hershfield

Harry Weeks

Parkersburg Academy

Raleigh

"Harry Shannon

Charles Daniel
Carlos Lucero

Regular Members

Tygarts Valley

Joseph A. Tavolacci

Boone

Ernesto Yutiamco

Extra Milers

Cabell

Mabel Stevenson

Kanawha

Cecilio Delgra

Harrison

Joseph Kassis
Louis Ortenzio Jr.

Kanawha

Moutassem Ayoubi
John Byrd
Vera Hoylman
Muhib Tarakji

Raleigh

Kalid M. Hasan

Alliance Members

Sustainer Members

Eastern Panhandle

Sara Townsend

Mercer Ohio

Generoso Duremdes Esther Weeks

166 THE WEST VIRGINIA MEDICAL JOURNAL

Special Memorial

IAN WILLIAM MARSHALL, M.D.

“There is a deep pathos in a life cut off in the promise of such
rich fruit. He will be numbered among the inheritors of
unfulfilled renown. ”

Sir William Osier

Osier’s words reflect the thoughts of many upon hearing of the
passing of Dr. Ian William Marshall. He died suddenly in his home
in Morgantown on March 8, at the age of 30.

Ian was bom in Morgantown on July 18, 1963, to Drs. Robert J.
Marshall and Mabel M. Stevenson, who were then on the medical
faculty at West Virginia University and now practice in Huntington.
He pursued his studies at the Mercersburg Academy in Pennsylvania
and Kenyon College in Ohio. In 1989, Ian returned to Morgantown
and received his M.D. degree from WVU. His medical training
included research in the Virology Laboratory at Marshall University
School of Medicine, which culminated in a co-authored
presentation at the 14th International Congress of Chemotherapy.
He then completed four years of residency in diagnostic radiology
at WVU Hospitals. Since 1993, he had devoted his skills in private
practice in North Central West Virginia with Radiology Consultants
Associated.

The influence of Ian’s parents upon him was unmistakable. The
elegance and strength of his mother and the regal dignity of his
father provided” ... that education in virtue from youth upwards,
which enables a man to pursue the ideal perfection” (Plato). Ian
achieved that ideal, both personally and professionally. He was
admired for his honesty and strength of character. In the words of
his elder brother, Stephen, he possessed a serenity, a stability of
mind and manner, and a maturity beyond his years. And at all
times, he maintained a reserved dignity.

It was his infectious laughter, his love of life, his insight and
thoughtfulness, and of course his trademark good nature and quick
wit that his friends most valued. In fact, these are the virtues that
made all of his friends consider Ian their best friend. If a man is
measured by the effect he has on the sum of his friends, then Ian’s
virtues are truly boundless.

Ian is survived by his parents; his brother, Stephen R. Marshall,
and his wife, Linda, of New York, N.Y.; his sister, Deirdre M.
Marshall, M.D., and her husband, Anthony Wolfe, M.D., of Miami,
Fla.; and his fiancee, Julia Chico, of Morgantown.

Ian will remain, for all of us, a cherished friend always.

Frederick J. Gabriele, M.D.

Pittsburgh, Pa.

Obituaries

Frederick H. Dobbs, M.D.

Dr. Fred H. Dobbs, 86, died April 3 at his home
in Charleston after a long illness.

Dr. Dobbs was born in Wheeling and attended
what is now West Virginia University when it was
still a two-year school. He completed his medical
degree at Rush Medical College at the University of
Chicago in 1934, and then interned at Swedish
Covenant Hospital in Chicago. His did his residency
at Sibley Memorial Hospital in Washington, D.C.

Dr. Dobbs served six years in the U.S. Navy
during World War II. He trained first in Pensacola,
Fla., during the early years of the war and then
became a flight surgeon assigned to the Marine
Corps and stationed in the South Pacific.

In 1947, Dr. Dobbs moved to Charleston and
began his practice as an obstetrician/gynecologist.
He worked 32 years before retiring at the age of 71.
In addition to being a member of the WVSMA, Dr.
Dobbs was the founder of the American College of
Obstetrics-Gynecology and a member of the AMA,
and the American Association of Obstetrics-
Gynecology.

A longtime member of St. John’s Episcopal
Church in Charleston, Dr. Dobbs helped found the
Order of Jerusalem, a service group of lay ministers
in the Episcopal Church. He was devoted also to
Manna Meal, a program which he was instrumental
in starting at St. John’s to feed anyone in need.

“He’d probably want to be remembered more for
his work with Manna Meal than anything else,” his
son, Thomas Dobbs said. “He even went to the
church and worked every day when he retired. He
used to clean the tables off and help serve the
food. He thought Manna Meal was great,” he
added.

Dr. Dobbs is survived by his wife, Pauline
Dobbs; sons, Dr. Frederick H. Dobbs II of
Titusville, Fla., and Thomas Dobbs of Charleston;
sister, Kathryn Wedemyer of West Palm Beach, Fla.;
and two grandchildren.

The family suggests memorial contributions to
Manna Meal, 1105 Quarrier St., Charleston, W.Va.,
25301.

Pastor C. Gomez, M.D.

Dr. Pastor C. Gomez, 73, of Williamson, died
November 21 at his home.

Born in the Philippines, Dr. Gomez was a
graduate of the University of Sancti Thomar. He
was a past coroner of Mingo County. A member of
the WVSMA since 1981, Dr. Gomez was also a
member of the Mingo County Medical Society, the
First Presbyterian Church of Williamson and the
Lions Club.

Survivors include his son, Douglas Gomez of
Webster, N.Y.; daughters, Kristina Sculac of
Bethleham, Pa.; and five grandchildren. He was
preceded in death by his parents, Pastor Pineda and
Nativida Cezzteno Gomez.

APRIL 1994, VOL. 90 167

West Virginia Medical Journal

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May 1994

West Virginia State Medical Association

Volume 90 No. 5

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McDonough Caperton Insurance Group
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itepl

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:DITOR

I itephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

4ANAGING EDITOR

4ancy L. Hill, Charleston

EXECUTIVE DIRECTOR

Teorge Rider, Charleston

\SSOCIATE EDITORS
John M. Hartman, M.D., Charleston
Joe N. Jarrett, M.D., Oak Hill
Robert J. Marshall, M.D., Huntington
David Z. Morgan, M.D., Morgantown
Louis C. Palmer, M.D., Clarksburg
Harvey D. Reisenweber, M.D., Martinsburg
Mabel M. Stevenson, M.D., Huntington

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Postmaster send form 3579 to the West
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Entered as second-class matter January 1,
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WEST VIRGINIA MEDICAL JOURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $36 a year in the U.S.;
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West Virginia Medical

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Contents

Feature Article

Travel medicine for West Virginians 178

Ohio County members pleased with their first mini-internship 182

Scientific Newsfront

The treatment of intracranial lesions with stereotactic

radiosurgery 186

Treatment of spastic gait in cerebral palsy 190

A case report of multimodality therapy

of bladder cancer 193

Manuscript Guidelines 194

Editorial

Motivations 199

In My Opinion

It’s time for tort reform! 200

Special Departments

General News 202

WVSMA Annual Meeting Registration Form 205

Continuing Medical Education 206

Medical Meetings/Poetry Corner 207

Bureau of Public Health News 208

Robert C. Byrd Health Sciences Center of WVU News 210

Marshall University School of Medicine News 212

Medical Student News 214

Obituaries/Society News 216

Classified 217

May Advertisers 218

Front Cover

Tulips in the gardens at the home of Paul and Nancy
Hill of Charleston dance in the spring breeze. Photo
courtesy of Nancy Hill , managing editor of the West
Virginia Medical Journal.

MAY 1994, VOL. 90 177

Travel medicine

GREGORY JUCKETT, M.D.

Assistant Professor of Family Medicine ,

Robert C. Byrd Health Sciences Center of
West Virginia University, Morgantown, W.Va.

Abstract

Preparation for overseas travel
often involves a prolonged search
for expertise and necessary
vaccinations that can be a formidable
challenge to patients and physicians
alike. Many primary care providers
find themselves ill-equipped to
provide up-to-date information for
travel to undeveloped countries
where there may be risks of diarrhea,
malaria and other exotic diseases.
However, basic travel advice can
easily be incorporated into most
practices with the help of regularly
updated reference materials such as
the CDC’s Health Information for
International Travel.

More advanced assistance along
with the necessary vaccinations is
available throughout West Virginia
at a number of travel clinics which
are discussed in this article. Through
greater awareness of travel issues
and timely referral physicians may
expedite their patients’ travel plans
while safeguarding their health
abroad.

Introduction

The world is rapidly becoming a
closer-knit community and therefore a
more inviting place for travel in spite
of its political woes. More people than
ever seem to be venturing abroad for
business, tourism, education, and
church or relief work. Travelers are
also becoming more adventurous and
more prone to stray off the beaten
path to destinations in the Third World.

While Europe is still popular, it is
not at all unusual to have your patients
aspire to an African safari, a trekking
adventure in Nepal, or a boat tour into
an Amazonian rain forest. So, it is
inevitable that even doctors practicing
in West Virginia will have to deal with

for West Virginians

the “travel bug” when it bites their
patients.

Possible case situation

What advice do you give your
patient, a 40-year-old diabetic pastor,
when he informs you that he will be
taking his recently pregnant wife and
two young children on a short-term
mission to Africa which will involve
travel through several undeveloped
countries? Are you ready to answer his
questions such as:

What sort of diseases could he and
his family could catch over there?

What should they take to keep
from getting diarrhea?

What can they take to reduce the
risk of malaria?

What happens if they get sick?

What insect repellents should be
brought along?

How can his diabetes be managed
if there is no electricity to keep his
insulin cold?

And finally the clincher — what
shots are needed and where can
you get them?

Solutions

You would not be alone if you felt
overwhelmed by such a barrage of
questions during a patient’s office
visit. Granted that this example of the
diabetic pastor is complex and some
health recommendations should have
already been made if there was a
sending agency, but it's best to be
prepared to answer the most basic
travel questions.

The answers to most of these types
of questions can be found in the
Center for Disease Control’s Health
Information for International Travel
published by the U.S. Dept, of Health
and Human Services, Public Health
Service, for $6. This yellow paperback
provides a wealth of information that
no office can really afford to be without.
Of course, travel advice changes
rapidly with time, so the CDC regularly
updates its information. There is a
24-hour, seven-day-a-week traveler’s

hotline available (404-332-4559) which
provides the most current guidelines (1).

It is especially important to realize
that the advice and vaccines you might
have received on your trip 10 years
ago are probably no longer valid for
the same destination today. For
instance, oral typhoid vaccination is
now replacing the painful injections of
the past, and malarial prophylaxis
recommendations have been completely
revised with the inexorable spread of
chloroquine-resistant strains.

Other travel risks

Always advise your patients to avoid
casual overseas sexual contact since it
may carry a high risk of transmitting
Hepatitis B or AIDS, not to mention
other sexually-transmitted diseases (1).
However, if sexual contact does occur,
condoms must be used; but, individuals
need to realize that even they do not
provide total protection.

Surprisingly, serious infectious
disease is much less of a threat to
travelers today than it was in the past
except in the most unhygienic of
circumstances. Studies of traveler
mortality have shown that infectious
diseases accounted for a tiny proportion
of overseas deaths (less than 1% in
some series) and that cardiovascular
disease and accidents, especially
motor vehicle accidents, are the real
killers (2). In other words, wearing a
seat belt, driving defensively, and
remembering to pack the nitroglycerin
will undoubtedly save more lives than
travel vaccinations and pills. Be sure
to put these risks into perspective for
your patients since it is unlikely
anybody else will do this for them.

Preventive measures

In spite of these facts, concern still
focuses on infectious disease, which
indeed remains an important source of
morbidity, if not mortality, for
travelers. The most common travel
questions can be lumped into three
main categories that can be covered
only briefly in this article: traveler’s
diarrhea, malaria prophylaxis, and
immunization recommendations.

178 THE WEST VIRGINIA MEDICAL JOURNAL

It is more important to emphasize
preventive measures than have the
patient develop a false sense of
security from having had his shots and
carrying a few pills. In underdeveloped
countries, it is prudent to avoid drinking
unboiled/untreated water and eating
uncooked, room-temperature food or
fruit (unless you have peeled it
yourself). It is helpful to remember
the classic warning: “Boil it, cook it,
peel it or forget it.” Even brushing
your teeth with tap water or having
ice in your drink (alcoholic or
otherwise) could result in a few' days
of misery.

In the tropics, and particularly in
malarious regions, insect repellents
are a must. Limit outdoor exposure
after dusk and wear protective, light-
colored clothing with long sleeves and
pants if you must be out. Spraying
clothing with permethrin (Permanone)
also helps, as do insect repellents
containing diethyl toluamide (deet) (4).
Excessive use of deet-containing
repellents on children’s skin may cause
neurotoxicity, so moderation is in
order. If there are no reliable window
screens, a permethrin-treated mosquito
net is worth its weight in gold even if
there is no malaria in the region.

For trips to Third World countries, it
is best to prepare a comprehensive
travel kit containing the following items:

1) An International Certificate of
Vaccination to document
vaccines received (available at
travel clinic),

2) Malaria prophylaxis medication,

3) Deet-containing insect
repellent,

4) Water purification tablets,

5) Oral rehydration salt packets,

6) Traveler’s diarrhea treatment
medication — possibly also
bismuth subsalicylate (Pepto-
Bismol) for prophylaxis or early
treatment,

7) Imodium AD for relief of
diarrhea symptoms,

8) Sunscreen,

9) Bandaids,

10) Spare pair of eyeglasses or
prescription for same,

11) Ample supply of regularly-
prescribed medications,

12) Thermometer,

13) Analgesic of choice,

14) Antiseptic for minor wounds,

15) Antifungal powder,

16) Toilet paper (remove roll to
pack); and

17) Motion sickness medication if
necessary.

Traveler’s diarrhea

Infectious diarrhea is likely to be
foremost on your patient’s mind and
with good reason. Even with
precautions, 20%-50% of travelers in
areas of high risk are likely to contract
it, often within the first week of arrival
(5). Fortunately, it is usually a benign
and self-limited disease, but even so it
can ruin a short trip and seem anything
but benign at the time.

Preventive dietary restriction remains
the best policy, and the CDC has
recommended that routine medical
prophylaxis be avoided by those in
good health. Nevertheless, people
entering high-risk areas for short but
critical visits may wish to protect
themselves with bismuth subsalicylate
or Pepto-Bismol (6). Two chewable
tablets four times a day (with meals
and at bedtime) for up to three weeks
can decrease the incidence of diarrhea
up to 60% (7). Longer courses than
three weeks are not recommended
and the traveler must also realize this
medication could discolor the tongue
or stool and even cause tinnitus.
Sensitivity to aspirin, peptic ulcer, and
bleeding disorders are also
contraindications. Although antibiotics
such as sulfamethoxazole trimethoprim
and doxycycline have been used as
effective prophylactic agents, they
have potentially serious side-effects
that may not justify their widespread
use in a healthy population.

It is reasonable, though, to give
your patient treatment options to use
if and when diarrhea occurs. Here
again, bismuth subsalicyclate is a
reasonable initial choice along with
loperamide (Imodium AD) and an
oral-hydration solution. High fever or
dysentery are not common with
traveler’s diarrhea, but if they occur,
loperamide should be discontinued
and medical attention sought. Severe
diarrhea is often treated today with
sulfamethoxazole (800 mg.) and
trimethoprim (160 mg.) twice daily for
three days, but because of increasing
resistance problems, ciprofloxacin
(Cipro) 500 mg. twice daily for three
days may eventually become the drug
of choice in adults, unless they are
pregnant (8).

Malaria prophylaxis

Malaria risk assessment is critical for
travelers in less developed areas and,
unfortunately, prophylaxis is becoming
more complicated as chloroquine
resistance spreads. Mefloquine (Lariam)
250 mg. weekly, starting one week
prior to departure and continuing for
four weeks after return, is now the

best available protection in much of
the world (9).

Currently, chloroquine can only be
used in the Middle East (including
Egypt), Hispanola, and Central
America west of the Panama Canal,
but it can sometimes be combined
with other agents if mefloquine is
contraindicated. Contraindications to
mefloquine include pregnancy,
children under 15 kg., neuropsychiatric
problems including seizures, certain
cardiac medications (including beta-
blockers, calcium-channel blockers,
quinidine), and possibly the need to
maintain excellent spatial discrimination
(e.g. pilots) (9). In parts of Asia,
especially Thailand, Cambodia and
Myanmar (Burma), malaria has
managed to become resistant to
mefloquine, making daily doxycycline
the best prophylactic agent in the
border areas of this region (9).

It is all too evident that today’s
options for malaria protection are
increasingly limited, and those available
are mostly unsatisfactory for pregnant
women and children. There is no
such thing as total protection with any
present regimen, so sulfadoxine/
pyrimethamine (Fansidar) is often
carried for presumptive malaria
treatment in the event that high fever
and chills do develop in a remote
region. Of course, medical treatment
should be sought as soon as possible
after Fansidar is taken and the
prophylactic agent continued.

Many popular tourist destinations in
countries where malaria is present
may be malaria-free (e.g. Nairobi and
Rio de Janeiro), and travelers may not
be at much risk if they remain in more
civilized areas and minimize exposure
to the night-feeding Anopheles
mosquito (1). Recommendations are
subject to change, and travel clinics
are usually better equipped than most
individual practitioners to decide
where and when to use malaria
prophylaxis.

Immunizations

Perhaps the most frequently
encountered problem with travel
immunizations is not allowing enough
time prior to departure to complete
the optimal series. Four weeks of time
is sufficient for most travelers with
reasonably complete, routine U.S.
immunization records. Many older
Americans lack basic immunizations
such as tetanus, however, and this
problem can easily be remedied in the
average physician’s office before
referral to the travel clinic. Although
certain vaccines are mandatory for

MAY 1994, VOL. 90 179

crossing borders, it is not necessary to
vaccinate the traveler against every
disease in the region unless that
individual is truly at risk.

There are many vaccine options
today for travelers, but not all are
equally effective or necessary. Cholera
vaccine, for instance, has a brief
limited effect and is usually not
recommended by the World Health
Organization (1,4). Some vaccines
such as Japanese B Encephalitis are
only used in very special cases, such
as when individuals are spending
more than one month in rural, rice-
growing regions in Asia (4). The very
low risk of travelers contracting this
mosquito-borne disease makes it
unnecessary for most Asian travel.
Similarly, meningococcal vaccine is
useful only in areas having seasonal
epidemics such as sub-Saharan Africa
(December - June) or in pilgrims
traveling to Mecca (4).

Other vaccines such as typhoid and
yellow fever have a broader
application and may well be
mandatory. Typhoid vaccine is now
started two weeks prior to departure
as an oral dose every other day for a
total of four doses. Oral typhoid and
polio are both live vaccines and
should be given at least two weeks
apart. A polio booster is recommended
if the patient is traveling to an area at
risk. Inactivated polio vaccine is
preferred for adults (over 18 years
old) if prior polio vaccination status is
uncertain (1).

Yellow fever vaccine is live and is
available only at approved yellow
fever vaccination centers. (Yellow
fever and cholera vaccination should
be at least three weeks apart.) In West
Virginia, these vaccination sites are
located in Morgantown, Huntington
and Charleston. Current vaccination
requirements are listed by country in
the CDC’s Health Information for
International Travel and are subject to
change.

Hepatitis prevention

Immune globulin is necessary to
protect against Hepatitis A when
travel to areas of very poor sanitation
is likely. The adult dose is 2 ml. IM
for a visit under three months and 5
ml. if staying longer than three
months (with doses to be repeated
every five months) (4).

There is no risk of AIDS transmission
with immune globulin prepared in the
U.S., and pregnancy is not a
contraindication. Although the
enterically-spread Hepatitis A is a very
real threat, Hepatitis B is much less

likely to be acquired as it is transmitted
by contact with blood or by sexual
activity. Hepatitis B vaccine (3 doses)
is recommended for health care
workers and people who anticipate
living in highly endemic areas for
more than six months, especially if
they are likely to have sexual contacts
or receive local medical/dental care (4).

Clinics in West Virginia

Travel medicine or emporiatrics, as
it is sometimes called, is obviously a
very complex discipline. Even with
the extensive reference materials,
most physicians would welcome the
opportunity to refer patients to a
regional travel center after answering
some of their basic questions. With
timely referral, such a facility could
sort out all the variables, consider
contraindications, give current advice,
and supply the necessary vaccines.
Some live virus vaccines such as
yellow fever are available at only a
few locations, so in many cases the
patient needs to be referred regardless.

Several clinics are now available
in West Virginia which offer
comprehensive travel advice and
vaccinations. The University Health
Service of West Virginia University in
Morgantown offers complete travel
counseling along with a wide array of
vaccinations including yellow fever,
cholera, typhoid (oral and injectable),
tetanus-diptheria, polio, Hepatitis B,
rabies, meningococcus, Japanese
encephalitis, MMR, and immune
globulin. The address and phone
number for this facility is: WVU Health
Service Travel Clinic, Box 9247,

Robert C. Byrd Health Sciences Center
of WVU, Morgantown, WV 26506;
(304) 293-2311.

In Charleston, travel services are
provided at two locations by the
Kanawha-Charleston Health
Department. The main office is
located at 108 Lee Street, Charleston,
WV 25301; (304) 348-0700; and the
Public Health Unit is housed at the
Charleston Area Medical Center (CAMC)
at 3101 MacCorkle Ave., S.E.,
Charleston, WV 25304; (304) 348-8160.
Vaccines at these sites include yellow
fever, cholera, typhoid, tetanus-diptheria,
polio, Hepatitis B, rabies (if special
ordered), MMR, and immune globulin.

The Cabell-Huntington Health
Department provides counseling and
vaccines for yellow fever, cholera,
typhoid, tetanus-diphtheria, polio,
Hepatitis B, MMR, rabies, and immune
globulin at 1336 Hal Greer Blvd.,
Huntington, WV 25701; (304) 523-6483.
Also in Huntington, the Travel Clinic

of University Family Physicians is able
to provide detailed travel advice based
on itinerary as well as survival skill
instruction for those venturing into
very remote or dangerous regions.

This clinic is run by Dr. John Walden
of Marshall University and is located
at 1616 13th Ave., Huntington, WV
25701; (304) 525-0275.

Infectious disease specialists (some
with tropical medicine experience) are
available at Marshall University, CAMC
and West Virginia University to assist
with specific disease concerns or
unusual illnesses that patients may
bring back from overseas. WVU's
MARS line (1-800-WVA-MARS)
provides easy, rapid access to such
expertise.

In conclusion, many patients and
their physicians become frustrated or
even confused while attempting to
negotiate the travel-preparation maze.
It is hoped that travel medicine, always
a somewhat arcane field, will become
somewhat less so with the help of
these resources within our state.

Acknowledgement

The author wishes to thank Ann
Walters, R.N., of West Virginia
University Health Service for her
assistance with this article.

References

1. Health Information for International Travel:
Center for Disease Control, U.S. Dept, of
Health and Human Services; 1992 Public
Health Service HHS Publication No. (CDC)
92-8280.

2. Hargarten SW, Baker TD, Guptill K. Overseas
fatalities of United States citizen travelers: an
analysis of deaths related to international
travel. Ann Emerg Medicine 1991;20:622-6.

3. Steffen R. Epidemiologic studies of traveler’s
diarrhea, severe gastrointestinal infections,
and cholera. Review of Infectious Diseases
1986 May-June;8 Suppl 2.

4. The medical letter on drugs and therapeutics,
1992 May 1 ;(34) Issue 869.

5. Strum WB. Update on traveler's diarrhea.
Postgraduate Medicine; (84)1:163-70.

6. DuPont HL, Ericsson CD. Prevention and
treatment of traveler diarrhea. N Engl J Med
1993,(328)25: 182 1-7.

7. DuPont HL. Ericsson CD, Johnson PC,

Bitsura JM, DuPont MW, dela Cabada FJ.
Prevention of traveler’s diarrhea by the tablet
formulation of bismuth subsalicylate. JAMA
1987;257:1347-50.

8. Ericsson CD, Johnson PC, DuPont HL,

Morgan DR, Bitsura JM, dela Cabada FJ.
Ciprofloxacin or Trimethoprim -
Sulfamethoxazole as initial therapy for
traveler’s diarrhea. Ann of Int Med 1987;
106:216-20.

9. Wyler DJ. Malaria chemoprophylaxis for the
traveler. N Engl J Med 1993;(329)l:31-7.

180 THE WEST VIRGINIA MEDICAL JOURNAL

FOR THE NASAL AND
NON-NASAL SYMPTOMS
OF SEASONAL
ALLERGIC RHINITIS

Clear Choice In
Antihistamine
Therapy

• Low incidence of adverse effects

Proven efficacy
Nonsedating *

The incidence of sedation with
CLARITIN Tablets (8%) was similar
to that of placebo (6%) at the
recommended dose.

Rapid-actingf

CARITIN Tablets started working
in some patients in as soon as
30 minutes; 65% of patients
experienced relief within 2 hours. '

Once-a-day dosing

Once-a-day

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From Start To Finish

• Over 1 billion patient days of
worldwide experience

* In studies with CLARITIN Tablets at doses 2 to 4 times higher than the recommended dose
of 10 mg, a dose-related increase in the incidence of somnolence was observed.

t Relief began in 13% of treated patients vs 4% of placebo-treated patients within
30 minutes IP=.04j. At 2 hours, 48% of patients receiving placebo experienced relief.
Distribution of onset times was significantly earlier for CLARITIN Tablets vs placebo IP=.03).

Claritin

ms (loratadine)

Please see following page for brief summary of Prescribing Information.

CLARITIN®

brand of loratadine

TABLETS

PRODUCT

INFORMATION

Long-Acting Antihistamine

DESCRIPTION CLARITIN Tablets contain 1 0 mg micronized loratadine, an
antihistamine, to be administered orally. They also contain the following
inactive ingredients: corn starch, lactose, and magnesium stearate.

Loratadine is a white to off-white powder not soluble in water, but very
soluble in acetone, alcohol, and chloroform. It has a molecular weight of
382.89, and empirical formula of C2HaCIN202; its chemical name is ethyl 4-
(8-chloro-5,6-dihydro-11W-benzo[5,6]cyclohepta[1,2-6]pyridin-11-ylidene)-
1-piperidinecarboxylate and has the following structural formula:

,oc2h5

JQC@

CLINICAL PHARMACOLOGY Loratadine is a long-acting tricyclic antihista-
mine with selective peripheral histamine H, -receptor antagonistic activity.

Human histamine skin wheal studies following single and repeated 1 0 mg
oral doses of CLARITIN Tablets have shown that the drug exhibits an anti-
histaminic effect beginning within 1 to 3 hours, reaching a maximum at 8 to
1 2 hours and lasting in excess of 24 hours. There was no evidence of toler-
ance to this effect after 28 days of dosing with CLARITIN Tablets.

Pharmacokinetic studies following single and multiple oral doses of lo-
ratadine in 115 volunteers showed that loratadine is rapidly absorbed and
extensively metabolized to an active metabolite (descarboethoxyloratadine).
The specific enzyme systems responsible for metabolism have not been
identified. Approximately 80% of the total dose administered can be found
equally distributed between urine and feces in the form of metabolic prod-
ucts after 10 days. The mean elimination half-lives found in studies in nor-
mal adult subjects (n = 54) were 8.4 hours (range = 3 to 20 hours) for
loratadine and 28 hours (range = 8.8 to 92 hours) for the major active
metabolite (descarboethoxyloratadine). In nearly all patients, exposure (AUC)
to the metabolite is greater than exposure to parent loratadine.

In a study involving twelve healthy geriatric subjects (66 to 78 years old),
the AUC and peak plasma levels (Cmax) of both loratadine and descarbo-
ethoxyloratadine were significantly higher (approximately 50% increased)
than in studies of younger subjects. The mean elimination half-lives for the
elderly subjects were 1 8.2 hours (range = 6.7 to 37 hours) for loratadine and
1 7.5 hours (range = 11 to 38 hours) for the active metabolite.

Loratadine, dosed once daily, had reached steady-state by the fifth daily
dose. The pharmacokinetics of loratadine and descarboethoxyloratadine are
dose independent over the dose range of 10 to 40 mg and are not signifi-
cantly altered by the duration of treatment.

In the clinical efficacy studies, CLARITIN Tablets were administered be-
fore meals. In a single-dose study, food increased the AUC of loratadine by
approximately 40% and of descarboethoxyloratadine by approximately 1 5%.
The time to peak plasma concentration (Tmax) of loratadine and descarbo-
ethoxyloratadine was delayed by 1 hour with a meal. Although these differ-
ences would not be expected to be clinically important, CLARITIN Tablets
should be administered on an empty stomach.

In patients with chronic renal impairment (Creatinine Clearance
< 30 mL/min) both the AUC and peak plasma levels (Cmax) increased on
average by approximately 73% for loratadine; and approximately by 120%
tor descarboethoxyloratadine, compared to individuals with normal renal
function. The mean elimination half-lives of loratadine (7.6 hours) and
descarboethoxyloratadine (23.9 hours) were not significantly different from
that observed in normal subjects. Hemodialysis does not have an effect on
the pharmacokinetics of loratadine or its active metabolite (descarboethoxy-
loratadine) in subjects with chronic renal impairment.

In patients with chronic alcoholic liver disease the AUC and peak plasma
levels (Cmax) of loratadine were double while the pharmacokinetic profile of
the active metabolite (descarboethoxyloratadine) was not significantly
changed from that in normals. The elimination half-lives for loratadine and
descarboethoxyloratadine were 24 hours and 37 hours, respectively, and
increased with increasing severity of liver disease.

There was considerable variability in the pharmacokinetic data in all stud-
ies of CLARITIN Tablets, probably due to the extensive first-pass metabolism.
Individual histograms of area under the curve, clearance, and volume of dis-
tribution showed a log normal distribution with a 25-fold range in distribu-
tion in healthy subjects.

Loratadine is about 97% bound to plasma proteins at the expected con-
centrations (2.5 to 100 ng/mL) after a therapeutic dose. Loratadine does not
affect the plasma protein binding of warfarin and digoxin. The metabolite
descarboethoxyloratadine is 73% to 77% bound to plasma proteins (at 0.5
to 100 ng/mL).

Whole body autoradiographic studies in rats and monkeys, radiolabeled
tissue distribution studies in mice and rats, and in vim radioligand studies
in mice have shown that neither loratadine nor its metabolites readily cross
the blood-brain barrier. Radioligand binding studies with guinea pig pulmo-
nary and brain H,-receptors indicate that there was preferential binding to
peripheral versus central nervous system H, -receptors.

Clinical trials of CLARITIN Tablets involved over 10,700 patients who re-
ceived either CLARITIN Tablets or another antihistamine and/or placebo in
double-blind randomized controlled studies. In placebo-controlled trials,
10 mg once daily of CLARITIN Tablets was superior to placebo and similar
to clemastine (1 mg BID) or terfenadine (60 mg BID) in effects on nasal and
non-nasal symptoms of allergic rhinitis. In these studies, somnolence oc-
curred less frequently with CLARITIN Tablets than with clemastine and at
about the same frequency as terfenadine or placebo. In studies with
CLARITIN Tablets at doses 2 to 4 times higher than the recommended dose

of 10 mg, a dose-related increase in the incidence of somnolence was
observed. Therefore, some patients, particularly those with hepatic or renal
impairment and the elderly, may experience somnolence.

In a study in which CLARITIN Tablets were administered at 4 times the
clinical dose for 90 days, no clinically significant increase in the QTc was seen
on ECGs.

INDICATIONS AND USAGE CLARITIN Tablets are indicated for the relief of
nasal and non-nasal symptoms of seasonal allergic rhinitis.

CONTRAINDICATIONS CLARITIN Tablets are contraindicated in patients
who are hypersensitive to this medication or to any of its ingredients.

PRECAUTIONS General: Patients with liver impairment should be given a
lower initial dose (1 0 mg every other day) because they have reduced clear-
ance of CLARITIN Tablets.

Drug Interactions: The coadministration of a single 20 mg dose of
CLARITIN Tablets (double the recommended daily dose) and a 200 mg dose
of ketoconazole twice daily to 1 2 subjects resulted in increased plasma con-
centrations of loratadine (180% increase in AUC) and its active metabolite,
descarboethoxyloratadine (56% increase in AUC). However, no related
changes were noted in the QTc on ECGs taken at 2, 6, and 24 hours after the
coadministration of loratadine and ketoconazole. Also, there were no sig-
nificant differences in clinical adverse events between CLARITIN Tablet
groups with or without ketoconazole.

Other drugs known to inhibit hepatic metabolism should be coadminis-
tered with caution until definitive interaction studies can be completed. The
number of subjects who concomitantly received macrolide antibiotics, cime-
tidine, ranitidine, or theophylline along with CLARITIN Tablets in controlled
clinical trials is too small to rule out possible drug-drug interactions. There
does not appear to be an increase in adverse events in subjects who received
oral contraceptives and CLARITIN Tablets compared to placebo.

Carcinogenesis, Mutagenesis, and Impairment ot Fertility: In an 18-
month oncogenicity study in mice and a 2-year study in rats, loratadine was
administered in the diet at doses up to 40 mg/kg (mice) and 25 mg/kg
(rats). In the carcinogenicity studies, pharmacokinetic assessments were
carried out to determine animal exposure to the drug. AUC data demon-
strated that the exposure of mice given 40 mg/kg of loratadine was 3.6
(loratadine) and 18 (active metabolite) times higher than a human given
10 mg/day. Exposure of rats given 25 mg/kg of loratadine was 28 (lorata-
dine) and 67 (active metabolite) times higher than a human given 10 mg/day.
Male mice given 40 mg/kg had a significantly higher incidence of hepato-
cellular tumors (combined adenomas and carcinomas) than concurrent con-
trols. In rats, a significantly higher incidence of hepatocellular tumors
(combined adenomas and carcinomas) was observed in males given
10 mg/kg and males and females given 25 mg/kg. The clinical significance
of these findings during long-term use of CLARITIN Tablets is not known.

In mutagenicity studies, there was no evidence of mutagenic potential in
reverse (AMES) or forward point mutation (CHO-HGPRT) assays, or in the
assay for DNA damage (Rat Primary Hepatocyte Unscheduled DNA Assay)
or in two assays for chromosomal aberrations (Human Peripheral Blood
Lymphocyte Clastogenesis Assay and the Mouse Bone Marrow Erythrocyte
Micronucleus Assay). In the Mouse Lymphoma Assay, a positive finding
occurred in the nonactivated but not the activated phase of the study.

Loratadine administration produced hepatic microsomal enzyme induc-
tion in the mouse at 40 mg/kg and rat at 25 mg/kg, but not at lower doses.

Decreased fertility in male rats, shown by lower female conception rates,
occurred at approximately 64 mg/kg and was reversible with cessation of
dosing. Loratadine had no effect on male or female fertility or reproduction
in the rat at doses of approximately 24 mg/kg.

Pregnancy Category B: There was no evidence of animal teratogenicity
in studies performed in rats and rabbits. There are, however, no adequate
and well-controlled studies in pregnant women. Because animal reproduc-
tion studies are not always predictive of human response, CLARITIN Tablets
should be used during pregnancy only if clearly needed.

Nursing Mothers: Loratadine and its metabolite, descarboethoxylorata-
dine, pass easily into breast milk and achieve concentrations that are equiv-
alent to plasma levels with an AUCmlll/AUCplasma ratio of 1.17 and 0.85 for the
parent and active metabolite, respectively. Following a single oral dose of
40 mg, a small amount of loratadine and metabolite was excreted into the
breast milk (approximately 0.03% of 40 mg over 48 hours). A decision
should be made whether to discontinue nursing or to discontinue the drug,
taking into account the importance of the drug to the mother. Caution should
be exercised when CLARITIN Tablets are administered to a nursing woman.

Pediatric Use: Safety and effectiveness in children below the age of 12
years have not been established.

ADVERSE REACTIONS Approximately 90,000 patients received CLARITIN
Tablets 10 mg once daily in controlled and uncontrolled studies. Placebo-
controlled clinical trials at the recommended dose of 10 mg once a day var-
ied from 2 weeks' to 6 months' duration. The rate of premature withdrawal
from these trials was approximately 2% in both the treated and placebo
groups.

REPORTED ADVERSE EVENTS WITH AN INCIDENCE OF MORE THAN 2%
IN PLACEBO-CONTROLLED ALLERGIC RHINITIS CLINICAL TRIALS
PERCENT OF PATIENTS REPORTING

LORATADINE

10 mg QD
n = 1926

PLACEBO

n = 2545

CLEMASTINE

1 mg BID
n - 536

TERFENADINE

60 mg BID
n = 684

Headache

Somnolence

Fatigue

Dry Mouth

Adverse event rates did not appear to differ significantly based on age. se I \
or race, although the number of non-white subjects was relatively small. I In

In addition to those adverse events reported above, the following adver: |
events have been reported in 2% or fewer patients.

Autonomic Nervous System Altered salivation, increased sweatin
altered lacrimation, hypoesthesia, impotence, thirst, flushing.

Body As A Whole Conjunctivitis, blurred vision, earache, eye pai
tinnitus, asthenia, weight gain, back pain, leg cramps, malaise, chest pai
rigors, fever, aggravated allergy, upper respiratory infection, angioneurot
edema.

Cardiovascular System Hypotension, hypertension, palpitations, syi
cope, tachycardia.

Central and Peripheral Nervous System Hyperkinesia, blepharospasn I"
paresthesia, dizziness, migraine, tremor, vertigo, dysphonia.

Gastrointestinal System Abdominal distress, nausea, vomiting, flatt
lence, gastritis, constipation, diarrhea, altered taste, increased appetiti
anorexia, dyspepsia, stomatitis, toothache.

Musculoskeletal System Arthralgia, myalgia.

Psychiatric Anxiety, depression, agitation, insomnia, paroniria, amnesi:
impaired concentration, contusion, decreased libido, nervousness.

Reproductive System Breast pain, menorrhagia, dysmenorrhea, vaginiti:

Respiratory System Nasal dryness, epistaxis, pharyngitis, dyspne;
nasal congestion, coughing, rhinitis, hemoptysis, sinusitis, sneezing, bror
chospasm, bronchitis, laryngitis.

Skin and Appendages Dermatitis, dry hair, dry skin, urticaria, rash, pri
ritus, photosensitivity reaction, purpura. I

Urinary System Urinary discoloration, altered micturition.

In addition, the following spontaneous adverse events have been reporte
rarely during the marketing of loratadine: peripheral edema; abnormal he
patic function, including jaundice, hepatitis, and hepatic necrosis; alopeci;
seizures; breast enlargement; erythema multiforme; and anaphylaxis.

DRUG ABUSE AND DEPENDENCE There is no information to indicate the *
abuse or dependency occurs with CLARITIN Tablets.

OVERDOSAGE Somnolence, tachycardia, and headache have been re
ported with overdoses greater than 10 mg (40 to 180 mg). In the event c
overdosage, general symptomatic and supportive measures should b
instituted promptly and maintained for as long as necessary. j

Treatment of overdosage would reasonably consist of emesis (ipecai
syrup), except in patients with impaired consciousness, followed by the ad
ministration of activated charcoal to absorb any remaining drug. It vomitinj
is unsuccessful, or contraindicated, gastric lavage should be performer
with normal saline. Saline cathartics may also be of value for rapid dilution
of bowel contents. Loratadine is not eliminated by hemodialysis. It is no
known if loratadine is eliminated by peritoneal dialysis.

Oral LDjo values for loratadine were greater than 5000 mg/kg in rats am
mice. Doses as high as 10 times the recommended clinical doses shower
no effects in rats, mice, and monkeys.

DOSAGE AND ADMINISTRATION Adults and children 12 years ol age anr
over: One 10 mg tablet daily on an empty stomach.

In patients with iiver failure, 10 mg every other day should be the start;
ing dose.

HOW SUPPLIED CLARITIN Tablets, 10 mg, white to off-white compresser
tablets; impressed with the product identification number “458" on onr /;
side; and “CLARITIN 10" on the other; high density polyethylene plastic bot
ties of 100 (NDC 0085-0458-03). Also available, CLARITIN Unit-of-Use pack ^
ages of 14 tablets (7 tablets per blister card) (NDC 0085-0458-01) and 3(
tablets (10 tablets per blister card) (NDC 0085-0458-05); and 10 x 10 table
Unit Dose-Hospital Pack (NDC 0085-0458-04).

Protect Unit-ot-Use packaging and Unit Dose-Hospital Pack Iron
excessive moisture. Store between 2 and 30 C (36 and 86 F).

Q I

Schering Corporation
Kenilworth, NJ 07033 USA

Rev. 9/93 17790803

SUCCESSFUL

MONEY

IANAGEMENT

We are pleased to announce the 1994 Successful Money Management Seminar schedule. In three exciting sessions,
the workshop introduces you to key concepts and practices of wise money management. You’ll learn how to minimize
your taxes, maximize your investment returns, and provide a secure future for yourself and your family.

Another Member Benefit From Your Association!

Areas of Discussion!

• 1993 Tax Law Overview

- Summary of the new Tax Law

- New Opportunities in tax planning

• Estate Planning

- The probate process

- Wills, Trusts, Estate Taxes

• Equity/Fixed Income Investments

- Stocks, Bonds, Ltd Partnerships

- Purchasing strategies, Asset allocation

• Retirement Planning

- Qualified Pensions (SEP's, 401 K, 403B)

- Select Benefit Plans

Seminars Consist of Three Sessions
6:00 PM - 9:30 PM

Lite Meal Sen’ed

Elkins Area

Beckley Area

Wednesdays

June 8th, 15th,

October 12 th, 19th,

& 22nd

& 26th

Martinsburg Area

Charleston Area

Wednesdays

July 13th, 20th,

November 2nd, 9th,

& 27th

& 16th

Clarksburg Area

Fayette County

Wednesdays

Thursdays

September 14th, 21st,

December 1st, 8th,

& 28th

& 15th

Registration Fee $250.00
Spouse Fee $125.00

Spouse’s fee waived if registered 10 days before start of seminar.

If you would like to have a special seminar done in your area, notify
the Medical Association. We will be happy to accommodate you.

I Elkins Area

June 1994

I Martinsburg Area

July 1994

Clarksburg Area

September 1994

□ Beckley Area

October 1994

□ Charleston Area

November 1994

□ Fayette County

December 1994

Reserve Your Place!

Don’t Wait!!!

Remember, spousal fee is waived if reservations are confirmed 10 days prior to the seminar date.
Return this self-addressed card, or call the WVSMA at (304) 925-0342.

Please Call Today!!!

Name

Spouse’s Name If Attending
Address

City State Zip

Phone Office

Ohio County members pleased with their first mini-internship

Nine interns, representing a variety of occupations
in the Wheeling community, participated in the Ohio
County Medical Society’s first mini-internship in March.
This program gave interns the chance to experience a
normal day with members of the society. Both the
interns and the doctors involved were extremely
positive about their interactions, especially OCMS
President Dr. Terry Elliott.

“I think the mini-internship is the best program our
society has participated in during the past few years,”
Dr. Elliott said. “The goodwill and mutual understanding
that it achieved is invaluable. Now, the members of the
OCMS that participated and the community leaders
who were the interns can communicate so much more
effectively. This is not just because now we now know
each other on a personal basis, but because we all
appreciate and understand so much better about what
is involved in each others’ professions.”

OCMS began their mini-internship with an
orientation on March 20. The following day, the interns
observed one certain physician as he/she performed
routine office visits, hospital rounds and surgery.

Interns were given beepers overnight in case their
physician was called in for an emergency. A breakfast
was then held in order to evaluate the program and
give the interns and physicians a chance to comment.

“All of the comments that were given at the
debriefing breakfast were so favorable that we plan on
having another program within six to 12 months,” Dr.
Elliott said. “Many of the physicians who were unable
to participate the first time are very eager to have the
chance to have an intern. In addition, the interns all
agreed that they would like to have at least two full
days with their physicians, so we will be expanding
the format of the program next time.”

OCMS is the second county medical society to host a
mini-internship program. Kanawha County Medical
Society has had two programs and Cabell County
Medical Society had their first program this month.

Judy Romano, M.D., enjoyed sharing the rewards of
pediatrics with intern Diane Vargo, a journalist for the
Wheeling News-Register.

Howard Monroe (left), talk show host for WOMP Radio, observes as
resident Dr. Joe Durkalski (right) and Dr. Terry Elliott, family practitioner
and director of the family practice residency program at Wheeling
Hospital, discuss X-ray results.

Dr. Max West, an emergency medicine physician, discusses a patient’s
treatment plan with Wheeling Fire Chief Cliff Sllgar.

Family Practitioner Dr. Michael Fortunato explains some of the paperwork
that emcompasses his day to intern Nicole Blanc, a reporter with WVPR.

182 THE WEST VIRGINIA MEDICAL JOURNAL

After observing Dr. Linda Linger perform a C-sectlon, intern
Diane Vargo admires the newborn in the nursery.

In the operating room. Wheeling Mayor Jack Lipphardt observes as Dr.
Phil Polack anesthetizes a patient’s broken thumb so a pin can be placed in
it after a skiing accident.

Wheeling Councilman Tim McCormick looks on as Dr. Clyde Campbell, Ph.D., president of West Liberty State College, watches

William Strauch, an ophthalmologist, examines a patient’s Internist Dr. Angelo Georges check a patient’s blood pressure,

eyes for signs of glaucoma.

Casey Swaney, a journalist with the Times Leader in Martins
Ferry, Ohio, compares different insurance forms with Dr.
Bruce Walmsley.

Larry Jones, Ph.D., superintendent of Ohio County Schools, and Dr. Carl
Kite, discuss an X-ray of a patient’s skull.

MAY 1994, VOL. 90 183

Ruth Ferguson
lost her sight, but
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Ruth did not know she had diabetes until
she began to lose her sight. She is
one of 14 million Americans
with diabetes. Unfortunately,
more than half do not know they
have it because diabetes can
strike silently. Like Ruth, many
will first learn about diabetes
when treated for one of its
complications - amputation,
kidney disease, blindness, heart
disease or stroke. Black Americans

have an increased risk of developing
diabetes and should know
the early warning signs
of frequent urination,
unusual thirst, extreme
hunger, frequent infections
or blurred vision.
The American Diabetes
Association is the nation's
leader in the fight against
diabetes - funding research,
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She's fighting back with the
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FERRELL P H 0 T 0 G R A P H I C S

Specializing in public relations and advertising
photography for the health care industry

1116 Smith Street Suite 217 Charleston, WV 25301 Phone: (304) 340^1254

cientific Newsfront

The treatment of intracranial lesions with
stereotactic radiosurgery

P. P. SINHA, M.D.

Associate Professor of Radiation Oncology
S. BLOOMFIELD, M.D.

Assistant Professor of Neurosurgery
G. K. SMITH. Ph.D.

Assistant Professor of Medical Physics and
Radiation Safety

Robert C Byrd Health Sciences Center of
West Virginia University, Morgantown, W. Va.

Abstract

Stereotactic radiosurgery is a new
method of delivering a high dose of
megavoltage, ionizing radiation
therapy to a localized area in the
brain in a single session. A substantial
variety of intracranial lesions can be
treated with the use of a stereotactic
head frame and set up of tertiary >
collimators on an existing linear
accelerator. This state-of-the-art
technique has been used since June
1992 at the Robert C. Byrd Health
Sciences Center of West Virginia
University in Morgantown.
Radiosurgery treatment has been
well tolerated by all 24 patients
treated thus far.

Introduction

Radiosurgery is defined as a non-
invasive method to stereotactically
deliver a high dose of megavoltage,
ionizing radiation to a localized area
in the brain in a single session. This
technique was developed by Lars
Leksell, M.D., a neurosurgeon in
Stockholm, Sweden, and it utilizes a
gamma knife machine which has 201
Cobalt-60 sources with a total activity
of 60 kilolcuries mounted on a
spherical shield weighing 18,000 kg.

Presently, there are 51 installed
gamma knife machines in the world
with 17 units in the United States. This
system requires construction of a space
with shielding that, in addition to the
cost of the unit, can bring the total
amount to more than $3 million just to
begin operating a gamma knife.

An alternative approach that
achieves the same result is to use a

linear accelerator by adding a tertiary
collimator and taking advantage of its
ability to emit a beam of X-rays while
moving in an arc around the patient.
Combining a series of arcs, each with
the table in a different position,
produces a small region of convergence
where the dose is very high, while the
surrounding normal tissues receive a
very low dose of radiation. This is the
same effect produced by the gamma
knife and the start-up costs are usually
only 10 percent of those necessary for a
gamma knife or even less.

There are currently more than 50
accelerator-based radiosurgery units in
the United States, including the unit
located in the Radiation Oncology
Department at the Mary Babb Randolph
Cancer Center in Morgantown.

Materials and methods

The stereotactic radiosurgery unit at
WVU consists of a stereotactic ring
and accessories, a set of circular
collimator and computer software
obtained from Leibinger, a German
neurosurgery supplier. A DEC 3100/48
computer system is being used to run
the treatment planning software. The
actual treatment is carried out on a
Siemen’s linear accelerator using 15
MeV X-rays.

Since June 1992, 24 patients have
been treated by radiosurgery in the
Robert C. Byrd Health Sciences Center
of WVU in Morgantown (Table 1). On
the day of the radiosurgery procedure,
the patient is admitted to the Same
Day Care Unit in Ruby Memorial
Hospital. The stereotactic frame is
placed on the patient’s head early in

Table 1.

Diagnosis Number of patients

Meningiomas

Single Brain Metastasis

Multiple Brain Metastases

Craniopharyngioma

Acoustic Neuroma

Pituitary Adenoma

Total

the morning and stereotactic CT scans
are taken.

The CT scans usually involve serial
2 millimeter cuts throughout the entire
brain. Typically, there are 40 to 50
transverse images for each scan. This
CT data is transferred to the radiosurgery
planning computer and the CT
coordinates are transformed into
stereotactic coordinates using the STP
program. The target volume and the
critical areas such as optic nerve, optic
chiasma, eyes, brain stem and others
are outlined on the CT images.

The goal of a radiosurgery treatment
plan is to keep exposure to the
eloquent areas of the brain below the
safe limits, but at the same time give

Table 2. PROTOCOL FOR QUALITY
ASSURANCE OF THE LLNAC
PRIOR TO TREATMENT

The physicist performs the following quality
assurance steps on the LINAC equipment
prior to each radiosurgery treatment session:

1. Install the stereotactic collimator
apparatus in the tray holder of the
LINAC. Set the standard collimator to
a field size of 5 x 5 cm.

2a. The LINAC will be run in “rotation"
mode to check the accuracy of the
dose delivered in representative
arches. The monitor units delivered
will be expected to equal the number
of monitor units required (+/-3%).

2b. Check the gantry and table isocenter
and laser beam alignment.

3. Mount the ring holder onto the LINAC
table.

4. Place patient on the treatment table
and fasten the ring in the ring holder.

5. Attach positioning apparatus to ring.

6. “Zero” positioning indicators.

7. Set the indicators to match target
coordinates obtained from the
stereotactic treatment plan.

8. Move the table so the lasers match the
position indicators.

9. Remove positioning apparatus from
the ring.

10. Place the fiducial plates to the ring
and take two double exposure port
films. Run computer analysis of these
films. The coordinator of the beam
intersection must agree with the target
coordinator from the treatment plan
within 1 mm. before treatment can
proceed.

186 THE WEST VIRGINIA MEDICAL JOURNAL

the tumor a lethal dose. Adjustments
in the treatment plans are made until
the entire team agrees that it is
appropriate. The treatment planning
process takes three or four more
hours depending upon the complexity
of the case.

Once the treatment plan is approved,
a series of quality assurance tests are
conducted to assure the accuracy of
the linear accelerator for radiosurgery
(Table 2). Following the satisfactory
completion of the quality assurance
procedures, the patient is placed on
the treatment table. The patient’s head
ring is clamped in place positioned so
the target coincides with the isocenter
(the common center of rotation of the
gantry and treatment table), and
orthogonal ports (PA and lateral) are
taken.

These films are then digitized into
the computer and analyzed using one
part of the STP program. This analysis
gives X, Y, and Z coordinates of the
target which must agree with the
coordinates from the treatment plan
within one millimeter before treatment
can begin.

A typical radiosurgery plan consists
of five to seven arcs focusing on the
stereotactically identified intracranial
target (Figure 1). Each arc is between
120 to 180 degrees (Figure 2). The arcs
are separated by moving the treatment
table around the isocentric area. Each
treatment arc takes two to three minutes
of linear accelerator time to deliver a
dose of 250 to 350 cGy to the
treatment volume. Thus, a typical
radiosurgery plan consisting of six
arcs takes about 20 to 25 minutes of
the machine time to deliver a dose of
1,500 cGy over the selected target.
Most frequently, an 80 percent isodose
line is selected to mark the border of
the treatment volume.

When the treatment is complete, the
frame is removed from the patient’s
head and he or she is observed
overnight after the radiosurgery
treatments.

Clinical results

Six patients with solitary brain
metastasis were treated by radiosurgery
to 1,500 cGy by the 6 arc technique at
the Mary' Babb Randolph Cancer
Center. Three patients died of
metastases in the lungs, liver and
other organs, and three patients are
still alive.

The follow-up CT scans of the brain
in all of these patients demonstrated
excellent tumor control. Figures 3-6
demonstrate CT scans of a patient

with single brain metastasis from lung
carcinoma with some shrinkage in the
lesion after external beam radiotherapy
to the whole brain with 3,000 cGy in
10 fractions and complete disappearance
of the lesion after radiosurgery.

Eight patients had multiple lesions
in the brain. Two lesions in five patients
and one lesion in three patients were
selected for treatment by radiosurgery
because of their location in very
critical areas. All these patients had
been treated by external beam
radiotherapy to the brain prior to the
radiosurgery. Five patients died of
progression of metastases in the bones,
lungs, and other organs, and the three
other patients are still alive. The
follow-up CT scans of the brains of all
the patients demonstrated regression
of the lesions treated by radiosurgery.

Meningiomas varying in size from
28 millimeters - 48 millimeters in
diameter have also been treated. An
average dose of 1,800 cGy was
delivered to the 80 percent isodose
line. All of these patients are alive and
subsequent CT scans after the
treatment have demonstrated marked
shrinkage in the lesions. None of the
patients experienced any undue
side effects of radiosurgery. In
addition, the patients with acoustic
neuroma, pituitary adenoma and
craniopharyngioma have been treated
and are doing well. Their follow-up
CT scans indicated marked decrease
in the tumor.

Radiosurgery has been well
tolerated in all of our patients.
Although the number of patients is
small and the followups had only
been conducted for one year, none of
the patients had neurological deficits
or brain necrosis requiring surgical
intervention. Only one patient had

generalized mild seizures which were
controlled with Dilantin. We had
made every effort to limit the dose to
the optic apparatus, brain stem,
pituitary, and other critical parts of the
brain to 800 cGy, which is well
tolerated.

Discussion

Stereotactic radiosurgery has been a
very effective technique for controlling
intracranial vascular malformations.
Lunsford et al (4) at the University of
Pittsburgh School of Medicine treated
251 patients with cerebral malformations
with radiosurgery, and the outcome
was complete obliteration in 85% - 100%
of patients with lesions less than
4 cm3, and 58 percent in the lesions
between 4 cm3 - 10 cm3.

Surgical resection remains the main
treatment for intracranial meningiomas.
Management of patients with recurrent
disease or with residual tumors is still
a problem. Surgery may be very
difficult in some meningiomas due to
their location, and surgical morbidity
and mortality may be high.

Management of intracranial
meningiomas by external beam
radiation therapy has also been
controversial. Meningiomas are ideal
tumors for radiosurgery because they
are usually well demarcated, do not
invade the adjacent brain tissues, and
are well demonstrated on the CT and
MRI scans. Kondziolka (6) reported 65
patients treated with radiosurgery,
with 16 of the tumors located in the
cavernous sinus regions. There were
no immediate side effects, and the
actuarial two-year growth control was
found to be 95 percent.

Brain metastases develop in 40 to
50 percent of patients dying of cancer,
and almost 40 to 50 percent of patients
with brain metastases have solitary
lesions. If the patients are untreated,
they have a median survival of four to
six weeks. Patients may survive 16 to

MAY 1994, VOL. 90 187

tLfS

Figure 4.

20 weeks if given whole-brain irradiation, and surgery may
be beneficial in a small number of patients.

In spite of whole-brain radiotherapy with or without
surgery, the recurrence rate is high. Fuller et al (2) treated
47 brain metastases in 27 patients at Stanford by
radiosurgery. They were able to achieve a radiographic
local control rate of 88 percent.

Acoustic neuromas are very disabling conditions with
hearing loss, ataxia, tinnitus, trigeminal sensory loss, and
facial weakness. Although microsurgery has been the
treatment of choice in unilateral tumors in young and
healthy patients, radiosurgery is an alternative treatment
and the preferred option in patients with recurrence after
microsurgery and in patients who have sufficient medical
problems to make surgery unacceptable. Linskey et al (3)
treated 101 patients with acoustic neuromas with
stereotactic radiosurgery and obtained a current tumor
control rate of 97 percent.

Figure 6.

In conclusion, stereotactic radiosurgery is a very new
method to deliver ionizing radiation therapy in a large
variety of intracranial lesions in a single session. It is a
very effective treatment for arteriovenous malformations,
acoustic neuromas, meningiomas, malignant glial tumors,
metastatic brain lesions and many other brain lesions.

188 THE WEST VIRGINIA MEDICAL JOURNAL

References

1. Alexander E, Loeffler J. Radiosurgery using
a modified linear accelerator. Neurosurgery
Clinics of North America 1992 January: lo7-90.

2. Fuller B, Kaplan I, Adler J, Cox R, Bagshaw M.
Stereotaxic radiosurgery for brain metastases:
the importance of adjuvant whole brain
irradiation. International Journal Radiation
Oncology Biology Physics 1992;23:413-18.

3. Linskey M, et al. Stereotactic radiosurgery
for acoustic tumors. Neurosurgery Clinics of
North America 1992 January: 191-205.

4. Lunsford et al. Stereotactic radiosurgery of
brain vascular malformations. Neurosurgery
Clinics of North America 1992 January
1992:79-80.

5. Lutz W, Winston K, Maleki N. A system for

stereotactic radiosurgery with a linear
accelerator. International Journal Radiation
Oncology Biology Physics 1988 February;
14:373-81.

6. Kondziolka D, Lunsford D. Radiosurgery of
meningiomas. Neurosurgery Clinics of
North America 1992 January:219-30.

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MAY 1994, VOL. 90 189

Treatment of spastic gait in cerebral palsy

HOWARD H. KAUFMAN, M.D.

JOHN BODENSTEINER, M.D.

BARBARA BURKART, P.T.

LUDWIG GUTMANN, M.D.

THOMAS KOPITNIK, M.D.

VERA HOCHBERG, Ph.D.

NINA LOY, P.T.

JEAN COX-GANSER, Ph.D.

GERRY HOBBS, Ph.D.

Department of Neurosurgery, Robert C. Byrd
Health Sciences Center of West Virginia
University, Morgantown, W.Va.

Abstract

The most common presentation of
cerebral palsy is spastic diplegia,
which in severe cases can impede
nursing care and in less severe
cases can impair a child’s ability to
move around with facility. A
procedure has been developed to
decrease spasticity in which there is
selective section of portions of the
dorsal roots L2-S2. In a series of
such operations in 19 children with
spastic diplegia, we were able to
decrease their spasticity significantly
with resultant improvement in motor
function and self care. Tljere were
no significant complications and
patient and family satisfaction was
high. Our experiences further
confirm existing evidence that this
procedure is very helpful and highly
recommended for selected children
with spasticity due to cerebral palsy.

Introduction

Cerebral palsy (CP) is a condition of
altered motor control due to central
nervous system lesions created during
prenatal or neonatal insults (1). It
occurs in 2/1,000 births and is defined
as non-progressive encephalopathy
involving motor function. There are a
variety of types of CP including
dyskinetic (athetoid, dystonic) and
spastic, which may be accompanied
by problems in mentation, sensation,
integration of function, and other
neurologic impairments.

The spastic types of CP may involve
one, all or any number of the four
limbs, but spastic diplegia which
involves both legs is the most
common, affecting 58%-65% of victims
(2,3). The usual clinical precursor of
spastic diplegia is the occurrence of

some degree of asphyxia in the
premature infant.

The pathophysiology of this
condition is subependymal, germinal
matrix hemorrhage or leukomalacia
related to hypoxia in the posterior
periventricular white matter where
corticospinal leg fibers descend.
Ordinarily these fibers would exert an
inhibitory influence on the level of
motor tone established by intrinsic
circuits in the spinal cord. Without this
dampening influence, tone and reflex
sensitivity are too high and spasticity
results, especially in the legs.

Spasticity is defined as a velocity-
dependent increase in resistance to
passive stretch. This is accompanied
by triggering of antagonistic muscles
and failure of inhibition of these
muscles. Hyperactive deep tendon
reflexes are seen, as well as weakness,
loss of dexterity, fatiguability, and
release of flexor reflexes, as well as
occasional balance problems. Stronger
muscles overcome weaker ones,
leading to contractures of muscles and
joints with decreased range of motion.

Non-operative treatment of
spasticity includes physical therapy to
prevent or retard contractures, altering
patterns of movement, and improving
strength, as well as the use of the
antispastic drugs baclofen and
dantrolene (3). Orthopedic operations
include lengthening or release of
muscles and tendons as well as
procedures involving bones. They
remain important for contractures and
deformities (3).

The evolution of neurosurgical
treatment ( 1 ) began in 1898 when
Sherington observed that division of
posterior roots decreased tone in
decerebrate cats. In 1913, Foerster
reported treatment of spasticity by
cutting the posterior roots from L2 to
S2 (sparing either L4 or L5). Then in
1978, Fasano and colleagues achieved
some success by performing surgery
at the level of the conus and cut only
the posterior rootlets which caused
excessive reflex activity.

Peacock modified the procedure,
using an L2-L5 laminectomy for
exposure to identify the roots of the
cauda equina where they exited the
dura. Peacock has performed the
procedure on both severely spastic
patients, even if retarded, whose
hygiene and comfort are impaired by
severe spasticity; and also on
intelligent and mobile patients whose

lifestyles are compromised by
spasticity and who may risk the
problem of contractures.

In a series of articles since 1982
(1,4-10), Peacock and his colleagues
have demonstrated that this procedure
is efficacious in decreasing spasticity
and that its effects persist. It has
succeeded in facilitating care in the
first group of patients previously
described, and improving function in
the second group. In the latter,
improved hand function, bowel and
bladder function, and even improved
vocal function have been observed.
Secondary improvements in behavior
as well as increased growth and
weight have also been suggested.

Side effects of this procedure have
been minimal. On rare occasions, it
has unmasked unrecognized
weakness and occasionally caused
some paresthesias which are almost
invariably short-lived. This procedure’s
value has been noted by patients and
families, and since 1985, it has been
adopted in many American centers.

Peacock’s results have been
replicated by other groups (2,3,11,12).
It has been suggested that the surgery
should be carried out before children
are 8 years old to enable non-walkers
to walk (12). In a DATTA survey
published in 1990, selective dorsal
rhizotomy was judged safe (69%
established or promising) and effective
(69%) for patients with ambulatory
potential, and safe (69%) and effective
(61%) for patients without ambulatory
potential (2). In this article, we report
the results of treating our first 19
patients with this technique.

Methods

All potential candidates for surgery
were examined by the neurosurgeon,
pediatric neurologist and physical
therapist at the same time. Initial
evaluation included a history which
concentrated on birth, orthopedic
procedures and appliances, and
functional level in activities of daily
living. The level of the patients’
abilities to care for themselves was
evaluated on a scale of 7-1 as shown
in Table 1.

After obtaining an average grade of
their self-care abilities, we also inquired
about wheelchair management and
transfers, but found there were too
many variables to make the
information suitable for analysis. In
addition, bowel and bladder control

190 THE WEST VIRGINIA MEDICAL JOURNAL

Table 1. Levels of Ability of Self Care
No Helper

7 = Complete independence (timely,
safely)

6 = Modified independence (device)

Helper

5 = Supervision

4 = Minimal assist (Child = 75%+)

3 = Moderate Assist (Child = 50%+)
Complete Dependence

2 = Maximal assist (Child = 25%+)

1 = Total assist (Child = 0%+)

were also assessed, as well as family
support, funding and resources at home.
(We have been able to secure support
from state agencies.)

Physical examination included
evaluation of spasticity, which
interferes with function or care, and the
presence of rigidity, dystonia,
hypotonia, athetosis, ataxia or
significant weakness in antigravity
musculature since these latter conditions
are contraindications to surgery.
Contractures are noted and the findings
are documented by videotape.

The following are other quantitative
assessments which are performed:

1. Muscle Tone: The modified
Ashworth scale (Table 2) was used
to determine muscle tone in hip
adductors, hamstrings, quadriceps,
and plantar flexors, and an average
of the four muscles on both sides
obtained. Elbow flexors and elbow
extensors were also examined.

2. Range of Motion: Passive range of
motion of hip flexion, knee flexion,
hip adduction and ankle dorsiflexion
was compared to full range of
motion (Table 3). The grades for
four joints on both sides were
averaged, and elbow extension was
assessed using the same scale.

3. Myotatic reflexes: The

brachioradialis, biceps, triceps,
quads, hamstrings, ankle jerks, and
hip adductor reflexes were tested
and graded 0-4, with 2 being
normal.

4. Static postures: Patients are scored
(Table 4) on their independence in
holding for 10 seconds the static
postures of prone on elbows, four-
point kneeling, short sitting, half
kneeling and standing, and these
scores are averaged.

5. Transitional movements: Patients
are evaluated (Table 5) for level of
independence and time to
accomplish the transitional
movements of quadruped kneeling
to side sitting, sitting to standing,

Table 2. Levels of Muscle Tone (After Ashworth and Bohannon)

0 = Hypotonic

less than normal, floppy

1 = Normal

no increase in muscle tone

2 = Mildly hypertonic

slight increase, 'catch' in limb movement or minimal
resistance to movement through half of the range.

3 = Moderately hypertonic

—

more marked increase in tone through most of the range
of motion but affected part is easily moved

4 = Severely hypertonic

considerable increase in tone, passive movement difficult

5 = Extremely hypertonic

affected part rigid in flexion or extension

Table 3. Levels of Range of Motion

4 = Full range of motion
3 = 75% of full range of motion
2 = 50% of full range of motion
1 = 25% of full range of motion
0 = No motion at joint

Table 4. Levels of Static Posture

5 = Child independently maintains posture

4 = Requires use of own unilateral upper
extremity support

3 = Requires use of own bilateral upper
extremity support

2 = Requires continued support by another
person

1 = Child must be held in position

0 = Child cannot be so positioned

tall kneeling to half kneeling, and
four-point kneeling to chair sitting,
and these scores are averaged.

6. Ambulatory ability: The ability to
ambulate 8 feet (Table 6) as well as
to stairclimb is graded and recorded.

Surgery is carried out through a
laminectomy, L1-L2 across SI. Once
the dura is opened, the motor roots of
L4, L5 and SI are identified on one side.
The sensory roots are isolated and
divided into three to seven rootlets.
Each rootlet is stimulated to see if this
causes excessive reflex movement.
Those that do are cut, although one
rootlet at least is usually left at each
level. Postoperatively, patients have
been noted to maintain a flexion
posture for several days and to have
some hypersensitivity of the legs.

The patient undergoes intensive
physical therapy after postoperative
recovery. Comprehensive postoperative
evaluations are carried out at six
months and one year to obtain
information about function. All
patients and/or families are asked at
six months and 12 months
postoperatively to rate their
satisfaction with the results of surgery.
A four-level grading was used
(unsatisfied, neutral, satisfied and very
satisfied). Examinations, including the
videotape, were repeated.

Table 5. Levels of Transitional
Movements

5 = Independently completes transition
without person, device or use of UEs
against self for support

4 = Completes transition with intermittent
balance support

3 = Completes transition but requires use of
UEs against self

2 = Child uses furniture, device or person
as object to assist self

1 = Child observably participates; therapist
must assist

0 = Child does not participate, therapist
performs the movement

Table 6. Levels of Ambulatory Abilities

5 = Functionally ambulatory without device
4 = Functionally ambulatory with device
(name device)

3 = Ambulates but not for functional use
(caiises)

2 = Has some method of locomotion
1 = Unable to locomote

Results

We evaluated 19 patients, ages 2
years to 10 years. There were 12
males and seven females. Nineteen
had follow-up at 6 months, while 12
of these have completed 12-month
evaluations (Table 7). Only one
patient had unsatisfactory follow-up
care due to irresponsible parents, and
he did poorly.

Muscle tone was improved in 17
patients. Initially, there was a marked
increase in tone, but after surgery the
average was halfway between normal
and slightly increased. This makes
handling and positioning much easier
for the patients and their caregivers.

Range of motion was improved in
17 patients. Two patients with
improved tone did not have improved
range of motion, while two patients
did not have improved tone but did
have improved range of motion.

These differences might be related to
the intensity of physical therapy after
surgery.

Myotatic reflexes were hyperactive
in all patients prior to surgery, and all

MAY 1994, VOL. 90 191

patients lost their myotatic reflexes
after surgery. Reflexes remained
diminished in all but two children
who regained their hyperactive
reflexes and did less well functionally.

Before surgery, the average patient
required the use of both upper
extremities to maintain a static
posture, whereas, after surgery they
required only one upper extremity for
support. This meant they had freed an
extremity for use which made them
more independent. In terms of
transitional movements, the patients
changed from needing the assistance
of someone else to assisting
themselves with the use of furniture,
devices, or persons to provide a stable
support, a significant improvement.

The ambulatory skills of these
patients were also greatly improved.
The patients who were not ambulatory
before the surgery, which was
apparently due to the basic
underlying lack of control, were now
able to bear weight, which aided
bone development and circulation in
the legs and functionally improved
their ability to transfer. Patients
already walking had improvement in
quality and speed, but only one of the
patients who was unable to stairclimb
gained this ability.

In terms of self care, the patients
went from providing only 50% of their
own care to providing 75% of their
own care. No patient either gained or
lost sphincter control, although we
did not investigate this in detail.

Eighteen patients and families were
very satisfied with the procedure, and
one was satisfied.

Conclusions

Our series confirms the reports of
others concerning the helpfulness of
selective dorsal root section for the
spasticity of cerebral palsy. There was
marked improvement in muscle tone
and spasticity, and there were
secondary functional gains such as
static posture, transition, ambulation,
self care and satisfaction, which
obviously improved the quality of life.

It is obvious to us, as well as to
other health care professionals who

Table 7. Postoperative Results in Cerebral Palsy Patients

19 PATIENTS

Muscle

Mean

Tone

SEM

(0-5)

Better

Same

Worse

Range of

Mean

Motion

SEM

(0-4)

Better

Same

Worse

Static

Mean

Posture

SEM

(0-5)

Better

Same

Worse

Transitional

Mean

Movement

SEM

(0-5)

Better

Same

Worse

Ambulate

Mean

(1-5)

SEM

Better

Same

Worse

Self Care

Mean

(1-7)

SEM

Better

Same

Worse

Pre-op

6-Months

2.9

1.5

0.2

0.7

17 (89%)
2 (11%)

2.7

3.6

0.1

0.5

16 (84%)
0

3 (17%)

3.0

3.6

0.3

0.2

16 (84%)
2 (10%)
1 ( 5%)

1.9

2.6

0.3

0.4

12 (63%)
5 (26%)
2 (10%)

2.7

3.2

0.4

0.3

7 (39%)
10 (56%)
1 ( 6%)

3.3

4.1

0.5

14 (78%)
3 (17%)
1 ( 6%)

12 PATIENTS

6-Months

12-Months

1.5

1.3

0.1

2 (17%)
10 (83%)
0

3.5

3.6

0.2

0.5

4 (33%)
6 (50%)
2 (17%)

3.4

3.6

0.3

0.9

6 (50%)
6 (50%)
0

2.4

2.7

0.4

8 (67%)
3 (25%)
1 ( 8%)

3.0

3.3

0.5

0.4

3 (27%)
8 (73%)
0

4.0

4.4

0.6

0.5

7 (63%)
3 (27%)
1 ( 9%)

have performed larger series and
statistical testing, that this operation
should be performed early in life,
probably any time after two years.

This is the time period when the
potential for relearning motor skills is
highest and before orthopedic
deformities occur which necessitate
corrective procedures that can
themselves lead to weakening of
critical muscles. Early surgery can
obviate the need for such procedures.

References

1. Peacock WJ, Staudt LA. Spasticity in cerebral
palsy and the selective posterior rhizotomy
procedure. J Child Neurol 1990; 5:179-85.

2. Diagnostic and Therapeutic Technology
Assessment (DATTA): dorsal rhizotomy.
JAMA 1990;264:2569-74.

3. Park, TS, Owen JH. Surgical management of
spastic diplegia in cerebral palsy. N Engl J
Med 1992;326:745-9.

4. Peacock WJ, Arens LJ. Selective posterior
rhizotomy for the relief of spasticity in
cerebral palsy. SA Medical Journal 1982;
62:119-24.

5. Peacock WJ, Arens LJ, Berman B. Cerebral
palsy spasticity. Selective posterior rhizotomy.
Pediat Neurosci 1987;13:61-6.

6. Staudt LA, Peacock WJ. Selective posterior
rhizotomy for treatment of spastic cerebral
palsy. In: Pediatric Physical Therapy,
American Physical Therapy Association.
Williams & Wilkins, 1989:3-9.

7. Arens LJ, Peacock WJ, Peter J. Selective
posterior rhizotomy: a long-term follow-up
study. Child’s Nerv Syst 1989;5:148-52.

8. Staudt LA, Peacock WJ, Oppenheim W. The
role of selective posterior rhizotomy in the
management of cerebral palsy. Inf Young
Children 1990:2:48-58.

9. Vaughan CL, Berman B, Peacock WJ.
Cerebral palsy and rhizotomy. A 3-year
follow-up evaluation with gait analysis. J
Neurosurg 1991;74:178-84.

10. Peacock WJ, Staudt LA. Functional outcomes
following selective posterior rhizotomy in
children with cerebral palsy. J Neurosurg
1991;74:380-5.

11. Albright AL. Selective posterior rhizotomies
for spasticity in children. J Prosthetics and
Orthotics 1989;2:54-8.

12. Steinbok P, Reiner A, Beauchamp RD,
Cochrane DD, Keyes R. Selective functional
posterior rhizotomy for treatment of spastic
cerebral palsy in children. Pediatr Neurosurg
1992;18:34-42.

192 THE WEST VIRGINIA MEDICAL JOURNAL

A case report of multimodality therapy of
bladder cancer

STEVEN C. KOUKOL, M.D.

DONALD L. LAMM, M.D.

JACEK T. SOSNOWSKI. M.D.

JACKIE S. SHRIVER, R.N.

Robert C. Byrd Health Sciences Center of West
Virginia University, Department of Urology,
Morgantown, W.Va.

Abstract

Recurrent transitional cell
carcinoma of the bladder can pose
many challenging treatment options.
We present an unusual case requiring
multiple forms of treatment and a
discussion of these treatments.

Introduction

The primary goal in the treatment of
transitional cell carcinoma (TCC) of
the bladder is to achieve a cancer-free
state, with preservation of the native
bladder being a secondary goal.
Treatment modalities for bladder cancer
include surgical resection, radiation
therapy, systemic and intravesical
chemotherapy, and intravesical
immunotherapy. A combination of
these treatment modalities is often
necessary to most effectively manage
a patient’s disease.

Documented resolution of invasive
bladder cancer with topically applied
intravesical chemotherapy has not
been reported, but complete responses
occur in about one third of the
patients treated with cisplatinum-
based combination chemotherapy. In
contrast to the lack of efficacy with
intravesical chemotherapy, complete
responses with intravesical BCG
immunotherapy have been verbally
reported, but not well documented.

We present a case of a patient with
recurrent TCC of the bladder who had
an apparent complete response of
muscle invasive TCC to intravesical
BCG immunotherapy. Treatment with
all four treatment modalities resulted
in bladder preservation for 10 years
before cystectomy ultimately became
necessary.

Case report

An 85-year-old man who presented
with Grade II superficial TCC of the
bladder in 1981 was first managed by
transurethral resection of the bladder

tumor (TURBT). Superficial recurrences
developed in 1982 and he was then
treated with a six-week course of
intravesical thiotepa.

In August 1986, diffuse carcinoma-
in-situ (CIS) was discovered and this
patient underwent immunotherapy
with Bacille Calmette-Guerin (BCG).
Follow-up in January 1987 revealed
Grade III T3a disease localized to the
dome, with resolution of the diffuse
CIS. CT scan showed a thickened and
irregular bladder wall with no
evidence of lymphadenopathv.

This patient subsequently
underwent a partial cystectomy and
pelvic lymph node dissection in March
1987. The final pathology specimen
was without evidence of disease.
Urinary cytologies remained suspicious,
but there were no recurrences until
March 1989, when a papillary lesion
near the right ureteral orifice and a
patch of CIS were discovered. These
were treated with intralesional
interleukin-2 (IL-2) injections under an
experimental protocol (2,000 units
intralesionally weekly for four weeks
and then monthly for five months),
and the lesions responded well. CIS
recurred in May 1990, and was treated
with intravesical mitomycin.

A transurethral resection of a
recurrent lesion in November 1990
revealed a Grade III, T2 lesion. He
then underwent treatment utilizing
another protocol with concomitant
external-beam radiation and
5-fluorouracil (5-FU). A dose of 2,000
rads was delivered over two weeks
with 5-FU being administered in a
dose of 1,000 mg./m2/d. intravenously
for 96 hours at the beginning of each
course of 2,000 rads. Three cycles
were given with a one-week rest
period between each cycle.

Early follow-up showed a complete
response until recurrence of a Grade
III, Ta lesion and CIS in October 1991 -
Investigational therapy with intravesical
Intron A (alpha-interferon) was then
initiated, but early follow-up showed
presence of T2 disease in January
1992. In March 1992, radical
cystoprostatectomy with ileal conduit
diversion was performed on this
patient at the age of 85.

The final pathology report
demonstrated one small focus of
Grade III, T2 disease with no residual
CIS. He has done well since and was

without evidence of recurrence at his
12-month follow-up.

Discussion

Early management of superficical
TCC of the bladder involves transurethral
resection. Muscle-invasive disease in a
surgical candidate is best treated by
cystectomy. Treatment decisions
become more difficult when patients
develop multiple superficial recurrences
despite treatment, or when minimal
muscle-invasive disease occurs in
patients who are not good surgical
candidates or refuse cystectomy. For
these patients, there are a variety of
treatment options, though some of
them are currently experimental.

During the first five years of this
patient’s disease, it remained superficial
and was managed by TUR alone.

When he presented with CIS in 1986,
BCG immunotherapy was given
intravesically. Response rates of CIS to
BCG range between 68% - 82% with
an average of 74% (1). It offers the
best response rate of any intravesical
agent currently available, since
mitomycin C has a reported response
rate of only 53% in CIS (2).

Partial cystectomy still has a role in
patients with highly-localized bladder
cancer (Stage T2-T3). The five-year
survival rate in this group has ranged
between 50% - 70% (3). It is certainly
a very viable option for patients with
localized muscle-invasive disease
desiring a bladder-sparing procedure
and is tolerated better than a cystectomy
in high-risk surgical patients.

For both of these reasons, our
patient underwent a partial cystectomy.
Since the pathology report showed no
evidence of cancer, it was either
completely removed with TUR (which
we considered unlikely), or eradicated
secondary to the effects of BCG
immunotherapy. We have heard
numerous verbal reports and previously
observed response of muscle-invasive
TCC to intravesical BCG (4).

Interleukin 2 (IL-2) is a lymphokine
produced by helper T-lymphocytes,
which induces proliferation of
activated T-lymphocytes including
lymphokine-activated killer (LAK)
cells. In 1984, Pizza and colleagues
reported complete tumor regression in
three of six patients with invasive
bladder tumors who were treated with

MAY 1994, VOL. 90 193

intralesional injection of IL-2 (5).
Sosnowski showed a significant
reduction in tumor volume of murine
TCC when the tumors were injected
with IL-2 (P=.01)(6). In our current
clinical trial, we have observed
complete responses in injected tumors
in three out of six patients. Two of
these responding patients had muscle-
invasive TCC, had failed multiple
previous treatments, and were not
candidates for radical cystectomy (7).

Radiation therapy alone for stage
B2 to C disease only results in about a
five-year survival rate of 25%. The
radiosensitivity of tumor cells has been
found to increase with 5-FU (8).
Russell had a 45-month survival rate
of 64% in 34 patients treated with
5-FU and radiation therapy as a
bladder-sparing protocol (9). Patients
with residual disease underwent
cystectomy, while those with complete
response were observed. Using a
similar protocol, our patient received
6,000 rads in combination with 5-FU
and had a complete response.
Therefore, observation was continued.

Alpha-interferon is currently being
studied in clinical trials. A Stanford-
NCOG study reported a 32% complete
response in 19 patients with CIS and a
25% complete response in 16 patients
with papillary tumor when treated
with intravesical alpha-interferon (10).
In addition, Torti had four of eight
patients with CIS achieve a complete
response (11).

With the persistence of muscle-
invasive disease despite multimodality
therapy, our patient finally consented
to undergo a recommended cystectomy.
Pathology surprisingly showed only a
small focus of Grade III muscle-
invasive TCC of the bladder. All pelvic
lymph nodes were negative for
metastasis.

Conclusion

This case presentation demonstrates
the natural course of a high-grade
bladder tumor treated with several
different regimens. We were able to
extend the life of his native bladder
by five years from the time of
development of muscle-invasive
disease and 10 years from the time
of initial presentation.

There is suggestion that this
patient had a complete response of
muscle-invasive disease to BCG
immunotherapy. In select patients
who have failed standard therapies
and who do not desire cystectomy,
these are some (but not all) of the
many treatment options currently
available.

Acknowledgement

The authors wish to thank Patty
VanGilder for preparing this manuscript.

References

1. Sosnowski JT, Lamm DL. Immunotherapy
for bladder cancer. In: Rous S, editor.
Urology Annual. Appleton and Lange, 1990;
4:123-56.

2. Lamm DL. Carcinoma in Situ. In:Urol Clin N
Am. W.B. Saunders, 1992 (Vol 19, No 19):
499-508.

3. Whitmore WF Jr. Management of invasive
bladder neoplasms. Sem Urol 1983;1:34-41.

4. Lamm DL, Thor DE, Harris SC, Reyna JA,
Stogdill VD, Radwin HM. BCG immunotherapy
of superficial bladder cancer. J Urol 1980;
124:38-42.

5. Pizza G, Sevsrini G, Menniti D, DeVinci C,
Corrado F. Tumor regression after
intralesional injection of interleukin-2 (IL-2)
in bladder cancer. Preliminary Report. Int J
Ca 1984;34:359-7.

6. Sosnowski JT, DeHaven JT, Riggs DR, Lamm
DL. Treatment of murine transitional cell
carcinoma with intralesional interleukin 2
and murine interferon gamma. J Urol 1991;
146:1164-7.

7. Sosnowski JT, DeHaven JI, Abraham FM,
Riggs DR, Lamm DL. Sequential
immunocytological evaluation of murine
transitional cell carcinoma during intralesional
Bacillus Calmette-Guerin and Interleukin-2
immunotherapy. J Urol 1992;147:1439-43.

8. Heidelberger C, Greisbach L, Montag BJ.
Studies in flourinated pyrimidin: II. effects
of transplanted tumor. Ca Res 1958;18:305-17.

9. Russell KJ, Boileau MA, Higano C, Collins C,
Russell AH, Koh W, et al. Combined 5-
Fluorouracil and irradiation for transitional
cell carcinoma of the urinary bladder. Int J
Rad Oncol Biol Phys 1990;19:693-9.

10. Torti FM, Shortliffe LD, Williams RD, Pitts
WC, Kempson RL, Ross JC, et al. Alpha-
interferon in superficial bladder cancer: a
Northern California Oncology Group Study.

J Clin Oncol 1988;6:476-83.

11. Torti FM, Lum BL. Superficial carcinoma of
the bladder: natural history and the role of
interferons. Sem Oncol 1986;13:57-60.

Manuscript Guidelines

All scientific manuscripts should be submitted on an IBM
compatible disc in Wordperfect 5.1 or in ASCII (generic).
They must be prepared in accordance with “ Uniform
Requirements for Manuscripts Submitted to Biomedical
Journals. ”

All manuscripts should include:

1. Title page

2. An abstract of no more than 150 words

3. Text

4. Acknowledgements

5. References in parentheses numbered consecutively. No
more than 25 references will be published free of charge.

6. Tables

7. Legends for illustrations

All persons designated as authors should qualify for
authorship. Each author should have participated sufficiently
in the work to take public responsibility for the concept.

Where reference is made to generically-designated drugs,
the first such reference must be followed by parentheses
containing its most commonly known trade name.

All scientific material is reviewed by the Publication
Committee and should be sent to The Editor, West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.

194 THE WEST VIRGINIA MEDICAL JOURNAL

June 28, 1994

West Virginia State
Medical Association

announces sponsorship of

1994 Medical Billing Seminar

A comprehensive , one-day seminar for persons
responsible for filing claims in physicians' offices

How Your Staff Will Benefit:

Representatives from Medicare, Medicaid and PEIA will discuss:

♦ Claims documentation

♦ Fraud awareness

♦ Helpful hints for claims submission

♦ Keys to successful claims processing, including electronic claims submission

♦ Simplifying the billing process

+ Managed care options to PEIA insureds
+ Common payment methodologies based on RBRVS

A representative of WVSMA will also present current topics of interest to
medical billing personnel relating to managed care.

Program Location & Information:

The Days Inn in Flatwoods

The seminar will start promptly at 8:30 a.m. and end no later than 4 p.m. Registration
fees are $50 for those attending from a WVSMA member's office, and $125 for non-
member office personnel. Fees include lunch, two refreshment breaks, handout materials
and a certificate of attendance.

Space is limited so register early! Return the registration form along with your
registration fee by June 24.

1994 Medical Billing Seminar Registration Form

Practice Name Contact Person

Address

Physician Name

Telephone

(You must supply WVSMA member name to receive the member discount)

Registration Fee

1 WVSMA Member Physicians' Offices
$50 per person - Total :

1 Non-member Physicians' Offices
$125 per person - Total:

Make checks payable to the West Virginia State Medical
Association. Payment must accompany form.

Fax

Name of Attendees

Mail form with total registration fee to:
WVSMA, PO Box 4106, Charleston, WV 25364

Cancer crosses all cultures

and all nationalities without
exception. So it stands to rea-
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experienced worldwide would
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top researchers in their field,
wherever they might be found.
Their search resulted in a
respected team of renowned spe-
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However, this search would

never have been successful with-
out a highly attractive institution.
Designed to provide the optimum
environment for the development
and application of effective cancer

treatments, The James house
remarkable research facilitie
within the same building as a
equally excellent treatment ces
ter. Because the organization

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ENERATION

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and veterinary med-
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while benefiting from the
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Every state medical society, 64 medical specialty
societies, and the American Medical Association
agree that any health system reform legislation must
contain the principles outlined in the letter below:

February 23, 1994

Dear Senator / Representative, reform legisiation that gives every

African universal cove J ^ ^ been articulated by n”“dation otour legislative agenda,

employment or economic status.

We beUeve that any measure adopted by the Congress shoul individuals,

and government m paying ^ physicians, and other providers.

. Assured o{ slowing the rate of growth in health spending.

. E^abl«hcomEetition in the marketplace as a ^ decisions.

• Giyesati^^ l° PCTITU toed ^ coordinated system that minirnizj

. flnunateneedlessbuEe^^ health system reform must leave medi

red tape, for patents, P^1CU^’ u icians and their patients.

*"***“““ .

We beUeve that to enable pt^ elements:

system reform also must contain these icet0 balance the growing corporate

and government domination of health car .

• Enton^Aspild^ylP^ litigation.

members without the threat of tpmmUst be enacted, including a

$250,000 cap on non-economic damages,

would minimize defensive me cm . ..-makers should be on how their

American Medical Association

Physicians dedicated to the health of America

Aerospace Medical Association
Medical Association of the State of Alabama
Alaska State Medical Association
American Academy of Child & Adolescent Psychiatry
American Academy of Dermatology
American Academy of Facial Plastic & Reconstructive
Surgery

American Academy of Family Physicians
American Academy of Insurance Medicine
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngic Allergy
American Academy of Otolaryngology —

Head & Neck Surgery
American Academy of Pain Medicine
American Academy of Pediatrics
American Academy of Physical Medicine
and Rehabilitation

American Association of Clinical Endocrinologists
American Association of Clinical Urologists, Inc.
American Association of Electrodiagnostic Medicine
American Association of Neurological Surgeons
American College of Allergy and Immunology
American College of Cardiology
American College of Chest Physicians
American College of Emergency Physicians
American College of Gastroenterology
American College of Legal Medicine
American College of Medical Quality
American College of Nuclear Medicine
American College of Nuclear Physicians
American College of Obstetricians and Gynecologists
American College of Physicians
American College of Rheumatology
American Fertility Society
American Gastroenterological Association
American Group Practice Association
American Medical Association
American Medical Directors Association
American Orthopaedic Association
American Orthopaedic Foot and Ankle Society
American Pediatric Surgical Association
American Psychiatric Association
American Roentgen Ray Society
American Society of Abdominal Surgeons
American Society of Addiction Medicine, Inc.

American Society of Anesthesiologists
American Society of Cataract and Refractive Surgery
American Society of Clinical Oncology
American Society of Clinical Pathologists
American Society of Colon and Rectal Surgeons
American Society for Dermatologic Surgery
American Society for Gastrointestinal Endoscopy
American Society of Hematology
American Society of Internal Medicine
American Society of Maxillofacial Surgeons
American Society of Plastic and
Reconstructive Surgeons, Inc.

American Society for Therapeutic Radiology
and Oncology
American Thoracic Society
American Urological Association
Arizona Medical Association, Inc.

Arkansas Medical Society

California Medical Association

College of American Pathologists

Colorado Medical Society

Congress of Neurological Surgeons

Connecticut State Medical Society

Contact Lens Association of Ophthalmologists, Inc.

Medical Society of Delaware

Medical Society of the District of Columbia

Florida Medical Association

Medical Association of Georgia

Hawaii Medical Association

Idaho Medical Association

Illinois State Medical Society

Indiana State Medical Association

Iowa Medical Society

Kansas Medical Society

Kentucky Medical Association

Louisiana State Medical Society

Maine Medical Association

Medical & Chirurgical Faculty of the State of Maryland

Massachusetts Medical Society

Michigan State Medical Society

Minnesota Medical Association

Mississippi State Medical Association

Missouri State Medical Association

Montana Medical Association

Nebraska Medical Association

Nevada State Medical Association

New Hampshire Medical Society

Medical Society of New Jersey

New Mexico Medical Society

Medical Society of the State of New York

North Carolina Medical Society

North Dakota Medical Association

Ohio State Medical Association

Oklahoma State Medical Association

Oregon Medical Association

Pennsylvania Medical Society

Radiological Society of North America

Renal Physicians Association

Rhode Island Medical Society

Society for Cardiovascular and Interventional Radiology

Society of Critical Care Medicine

Society for Investigative Dermatology, Inc.

Society of Nuclear Medicine
South Carolina Medical Association
South Dakota State Medical Association
Tennessee Medical Association
Texas Medical Association
Utah Medical Association
Vermont State Medical Society
Medical Society of Virginia
Washington State Medical Association
West Virginia State Medical Association
State Medical Society of Wisconsin
Wyoming Medical Society

Editorial

Motivations

What gives our assailants the idea
they can improve Medicine by
degrading doctors? Most of us are
smart enough to make a living doing
something else which is not degrading
and which will give some status.
Recently, some doctors have started
doing exactly that.

It is no secret that a very common
motivation toward a career in Medicine
is the opportunity to be the good guy,
the giver, the one who wears the
white hat. Young men and women are
motivated to study, work and to put
off establishing families by the lure of
gaining status, respect and regard
from the community and the patients
they care for.

These thoughts come to mind when
reading a newspaper account of Ralph
Nader berating Senator Rockefeller for
supporting some version of tort reform
in Congress. Mr. Nader is reported to
have given a statistic alleging that U.S.
doctors are responsible for 80,000
deaths each year in hospitals alone.
The source of this statistic is not cited.
He added that it is “criminal” for
doctors to refuse to perform certain
operations because they fear
malpractice litigation.

Who is to protect the public from
the lies, distortions and fear
engendered by the likes of Mr. Nader?
We know the role of fear and anxiety
in dissuading patients from seeking
treatment. Unfortunately, Mr. Nader is
an influential man to whom people
listen as he mutters his dark warnings
and implied advice to avoid medical
care. He can be held personally
responsible for an untold and

immeasurable amount of pain,
suffering and death via the fear-
induced avoidance of needed medical
care resulting from his comments.

It could be easily maintained that it
is “criminal” for Mr. Nader or anyone
to foster or promote pain, suffering
and death on such a large scale. What
government agency, what enlightened
court will bring him to task? Who is to
punish him and assess punitive
damages for the pain and suffering he
causes? If he were just a stockbroker
lieing and offering bad, misleading or
self-serving advice, the SEC would put
him in jail or, at the very least, fine the
firm that employed him. Is it just that
our regulatory and punitive systems
are only stirred to action if a definable
number of dollars are involved?

Mr. Nader is not alone in
characterizing doctors so badly. He is
just one of the worst. His opinions
and remarks damage not only the
people he frightens away from
medical care, but also those
individuals considering a career in
Medicine and the doctors already
practicing who need just one more
reason to try something else.

A major criticism of doctors by Mr.
Nader and others for many years has
been, “they make too much money.”
Anyone having an interest in the
subject, however, would find that high
income in Medicine is simply a
byproduct of the work done — rarely
is wealth the primary goal of anyone
entering Medicine. It is simply
something that happens as a result of
doctors’ industry. Efficiency analysts
looking at the productivity of doctors

have consistently found that because
other industries and professions lag so
far behind, it is difficult even to name
another in second place.

It is perhaps possible to attract
another breed of applicants to
Medicine, a breed akin to the security
seekers in the U.S. Post Office or any
other government bureau. It seems
likely, however, that these too would
decline and unwilling candidates
might need to be conscripted into any
of the proposed government-run
medical services being considered in
Washington.

An unlimited amount of money is
inadequate to overcome the handicaps
of undeserved criticism, abuse,
vulnerability to suit, second guessing
by review bodies and the awareness
of a missing sense of dignity ordinarily
expected to accrue as a result of one’s
efforts. If a government-dominated
health care system comes to pass, the
practice of Medicine will become a
burdensome series of tasks
accompanied by a sense of futility and
of shame rather than a sense of pride -
futility over the impossibility of
dealing with a deadening bureaucracy
in any self-respecting way; and shame
over having passively accepted such a
situation.

It’s likely too that in such
circumstances, a trip to the doctor will
be equally as burdensome and
distasteful for anyone required to seek
care. The bright spot, however, is that
care will indeed be cheap.

- Stephen D. Ward, M.D.

Editor

MAY 1994, VOL. 90 199

In My Opinion

It’s time for tort reform!

President Clinton’s determination to
enact national health care reform
will ultimately rest on the efforts of
individual state legislatures to create
efficient, cost-effective, viable solutions.
At the forefront of the debate on this
issue will be the future of malpractice
litigation.

Since 1979, total compensation paid
by insurers for medical malpractice
claims has risen 25 percent annually.
Nationally, 900 new malpractice
lawsuits are filed each day, with an
average award of $300,000 (1). In
West Virginia, there has been a 2,770
percent increase in the number of
malpractice claims filed per year
between 1980 and 1989, and over
$123 million in awards has been paid
out during this period (2). Since one-
fourth of the cases have been
dismissed or not been awarded
damages, the legitimacy of many
claims has come into question.

In a 1991 article in the Journal of
the Royal Society of Medicine, J.S.
McQuade stated that the “malpractice
crisis” has disruptive but non-
quantifiable effects such as impairing
the doctor/patient relationship,
lowering job satisfaction and morale,
and damaging the professional
relationships between doctors and
lawyers. In addition, he stated that it
contributes to the practice of
“defensive medicine” in an attempt to
avoid litigation, such that two-thirds of
every doctor’s practice expenses are
the result of defensive measures! (3).

McQuade’s conclusions are further
strengthened by the American Medical
Association’s findings that 66 percent
of doctors admit ordering more tests,
and 70 percent order more consultations
because of liability concerns. About 26
percent of physicians waste in excess
of $100,000 (1). These intolerable
figures amount to billions of dollars
wasted annually.

The process of medical malpractice
litigation is so time-consuming that
lawyers rarely take a case unless
damages are likely to reach at least
$100,000. In addition, only 25 percent

of each liability dollar awarded
actually reaches a successful plaintiff
because of excessive legal fees,
paperwork, expert witnesses, etc. (4).
Pure economics dictate that resulting
higher malpractice insurance premiums,
while absorbed to some degree by
physicians, are mostly shifted to
consumers via increased fees. We are
simply feeding the system rather than
ensuring injured individuals their
deserved compensation.

In an attempt to resolve these
inequities, the Department of Health
and Human Services’ Task Force on
Medical Liability and Malpractice
released 30 recommendations for state
plans. In 1986, over 1,400 bills were
introduced in the 44 state legislatures
in an attempt to address the alleged
liability insurance crisis. More than
three-fifths of the states enacted some
form of tort reform in that year (5).

The West Virginia Medical Professional
Liability Act of 1986 included a range
of progressive measures including:

(1) The abolition of the locality rule
and the ad damnum clause;

(2) The placement of a $1 million
cap on “non-economic” damages
in a claim;

(3) The provision for an expert
witness in cases; and

(4) A statute of repose to limit the
period of time a suit can be
filed following an incident of
negligence (6).

These modifications, however, have
proved to be insufficient to curb the
costs of health care, and have only
affected a few cases. Stricter limitations
are needed to control the growing
problem, and I suggest the creation of
a pre-trial screening panel consisting
of a rotating jury of two physicians,
two attorneys and an expert from the
state health board. This would serve
to encourage early settlement of
meritorious claims while discouraging
frivolous suits. The Massachusetts
program finds about 50 percent of its
cases to be unfortunate medical results
rather than examples of negligence (7).

As another deterrent to nuisance
suits, I propose to make the
solicitation of a person with a
personal injury claim a misdemeanor
punishable by heavy fines. Michigan
has had some success with this
approach and even has a provision for
six-months’ imprisonment (8).

Another promising reform could be
the creation of standardized practice
guidelines for each specialty and
procedure. All physicians who
demonstrate compliance with the
designated guidelines would not be
liable for the outcome. To be allowed,
suits must include an affidavit from a
medical specialist stating that care
deviated from the standards. By
controlling the practice of defensive
medicine and the fear of lawsuits,
competent doctors would practice
with confidence while incompetence
could be discovered and rectified.

This concept is discussed in President
Clinton’s original health plan, but it
must be enforced and regulated at the
state level.

Other postulated reforms may show
considerable promise in the West
Virginia system. A collateral source
rule requiring recovery amounts to be
reduced by the amount received from
other sources could help reduce the
average insurance premium. Limitations
on contingency fees would greatly
reduce the final amount of excessive
claims. Absolute caps on the total
damages awarded exist in 27 states
and should be seriously considered in
West Virginia.

The major obstacle to these
proposed reforms, as other states have
experienced, is the unwillingness of
all sides to grant concessions. To
derive a comprehensive solution,
there must be a three-sided consensus
among the health care providers, the
trial lawyers, and the medical
insurance companies. Lawyer-dominated
legislatures must look beyond
allegiance to their trial bar colleagues
and realize the necessity for
responsible legislative action.

200 THE WEST VIRGINIA MEDICAL JOURNAL

Other states have demonstrated
tremendous potential for cost-effective
reform. Indiana instituted a barrage of
tort reform measures that resulted in a
92 percent decrease in the incidence
of malpractice claims (4). We now
have the opportunity to establish a
comprehensive malpractice litigation
system under the auspices of a
national health care scheme. A plastic
Health Security Card will not provide
health care to anyone. That
responsibility falls on the dedicated
health professionals of this great state.

Brian Caveney
Pre-Med Student
West Virginia University

References

1. Lesher DL. Health care reforms everybody
wants. Business News 1993 Oct 3.

2. Medical malpractice cases and awards
(special article). W Va Med J 1991;87(4):147.

3. McQuade JS. The medical malpractice
crisis - reflections on the alleged causes
and proposed cures (discussion paper). J of
the Royal Society of Medicine 1991;84:407-
11.

4.. Edwards F. Medical malpractice:solving the
crisis. New York:Holt and Co., 1989.

5. Talmadge PA, Peterson ND. In search of a
proper balance. Gonzaga Law Review 1987;
22(1):259.

6. Cleckley FD, Hariharan G. A free market
analysis of the effects of medical malpractice
damage cap statutes:can we afford to live
with inefficient doctors? W Va Law Review
1991 ;94(1):I-71 .

7. McLaughlin WH. A look at the Massachusetts
malpractice tribunal system. Am J of Law
and Medicine 1977;3:197-207.

8. Seidel GJ. Malpractice reform in Michigan.
Detroit College of Law Review 1976;235-56.

Editor’s Note: Brian was a national
finalist at the Truman Scholar
Competition in March at the University
of Michigan with this essay. He is a
senior at WVU, who maintains a 4.0
G.P.A. in his double major of
chemistry and biology. After he had
been at WVU only two and a half
years, he was accepted to the WVU
School of Medicine, which he will be
entering in the fall of 1995.

The Hospital Medical Staff Section 23rd Assembly Meeting

June 9-13, 1994 Chicago Marriott Hotel Chicago, Illinois

Interactive

Dialogue

with

AMA Board
of Trustees

Physician

Involvement

Health

System

Reform

With health system reform legislation pending before Congress, state health system reform
initiatives, and the rapid development of integrated delivery systems, it is vitally important that
medical staffs mobilize to stand up and speak out for patients and the profession. The June
Assembly meeting is no exception. Now perhaps more than ever before, HMSS representatives
need to be involved in shaping the nation's future health care system.

HMSS past actions have made a difference. The AMA has incorporated many issues advocated by
HMSS in its new health system reform proposal for action and model legislation. Basically, the
draft bill:

• requires that health plans establish a medical staff structure with defined rights with regard
to the plan’s medical policy, utilization, quality and credentialing and management issues;

• expressly permits physicians to jointly present their views on any plan issue (without boycott
or strikes) to plan management for discussion and negotiation;

• directly aids physicians in the creation of their own plans or networks to compete with large
insurance companies;

• requires negotiation of new regulations with the profession before their announcement ; and

• expands the role and protection for the profession’s accreditation, standard setting and medical
society disciplinary functions.

Success will depend on unified physician support and action. Mark your calendar
and plan to attend!

For more information please call

American Medical Association

312 464-4754 or 464-4761 Physicians dedicated to the health of America

MAY 1994, VOL. 90 201

General News

At Annual Meeting

Flink Address to focus on preventive medicine

Richard S. Lang, M.D.,

F.A.C.P., head of the Section of
Preventive Medicine at the Cleveland
Clinic Foundation, will deliver this
year’s Edmund B. Flink Address on
Friday, August 19 at the WVSMA’s
1 27th Annual Meeting at The Greenbrier.
Entitled “Prevention in the 1990s,” Dr.
Lang’s lecture will begin at 9:30 a.m.,
during the First Session of the WVSMA
House of Delegates.

Dr. Lang received his A.B. degree in
biology from Harvard College and then
obtained his medical degree at the
University of Cincinnati in 1979. He
completed a residency in internal
medicine at the Cleveland Clinic
Foundation from 1979-82, and during
this time he also worked as a senior
clinical instructor at Case Western
Reserve University Medical School in
Cleveland.

In 1982, Dr. Lang was named
director of Affiliated Residency Programs
at St. Vincent Charity Hospital and
Health Center in Cleveland. He held
this post for four years, and during
this time he rejoined the faculty at Case
Western as a senior clinical instructor,
a position which he still holds today.

Since 1986, Dr. Lang has been a
staff physician in the Department of
General Internal Medicine at the
Cleveland Clinic Foundation, where
he was named associate director of
the Internal Medicine Residency
Training Program in 1989 and head of
the Section of Preventive Medicine in
1990. In addition to these roles, Dr.
Lang is currently on the faculty of the
College of Medicine of Pennsylvania
State University and of the Ohio State
University College of Medicine.

A medical examiner for the FAA
since 1986, Dr. Lang is certified by
American Board of Internal Medicine,
the American Board of Preventive
Medicine in Occupational Medicine
and the American Board of Internal
Medicine in Geriatric Medicine. He is
a fellow of the American College of
Physicians, the American College of
Preventive Medicine, and of the Royal
Society of Medicine. Dr. Lang is also a
master of the American College of
Occupational and Environmental
Medicine and holds memberships in

Dr. Lang

several other national and state
medical organizations.

In addition to serving in many
capacities on committees at the
Cleveland Clinic Foundation, Dr. Lang
is involved in many research projects.
He has co-authored several books and
chapters, as well as had articles printed
in Southern Medical Journal, the
Cleveland Clinic Journal of Medicine
and other scientific publications.

The Edmund B. Flink Address was
established by Derrick L. Latos, M.D.,
F.A.C.P., four years ago when he was
president of the WVSMA, to honor Dr.
Flink, a professor emeritus at WVU.

Dr. Flink was chief of medicine for 16
years at WVU, and then in 1976 he
became a Benedum professor who
also served as an attending physician
at the WVU Health Sciences Center
until his death in 1992.

During his career, Dr. Flink had a
major influence on medical education
for many physicians in the state,
including Dr. Latos who had been one
of his students. Dr. Latos created the
Flink Address not only to recognize
Dr. Flink, but to provide an annual
internal medicine lecture on a topic
that had not only profound historic
value, but also had current implications.

A registration form for this year's
meeting appears on page 205. For
other information concerning the
WVSMA’s Annual Meeting, contact
Nancie Diwens at (304) 925-0342.

WVSMA is sponsoring a
comprehensive workshop entitled
the “1994 Medical Billing Seminar”
for individuals responsible for filing
claims in physicians’ offices. This
seminar will be held on Tuesday,
June 28 from 8:30 a.m. - 4 p.m. in
Flatwoods at the Days Inn, and it
will feature representatives from
Medicare, Medicaid, PEIA and the
WVSMA.

Topics to be discussed at the
meeting include claims
documentation, fraud awareness,
helpful hints for claims submission,
keys to successful claims processing,
simplifying the billing process,
managed care options to PEIA
insureds and common payment
methodologies based on RBRVS.

Registration fees are $50 per
person for staff members of WVSMA
members, and $125 per person for
non-members. Fees include lunch,
two refreshment breaks, handout
materials and a certificate of
attendance.

Space is limited, so register early
by mailing in the registration form
which appears on page 195 in this
issue of the Journal.

202 THE WEST VIRGINIA MEDICAL JOURNAL

Two Lunch and Learn programs set for Annual Meeting

Dr. Woerth Dr. Weeks Dr. Stephens

As a result of the extremely
successful Lunch and Learn programs
which were presented at last year’s
WVSMA Annual Meeting and at the
WVMSA’s Mid-Winter Clinical
Conference, two more of these
educational luncheons are planned for
this year’s WVSMA Annual Meeting at
The Greenbrier in August.

The first Lunch and Learn is entitled
"Managed Care . . . Minimizing the
Risks,” and it will be held on Thursday,
August 18 from noon - 1:30 p.m. This
session will feature Jan Woerth, Ph.D.,
president of J.K. Woerth, Inc., a
medical management consulting firm
with offices in Washington, D.C. and
Florida. The second Lunch and Learn
will take place the following day from
noon - 1:30 p.m. and will focus on
"The Shifting Winds of Quality7
Oversight.” This program will be
conducted by Harry S. Weeks Jr., M.D.,
president and director of the West
Virginia Medical Institute, and Mark K.
Stephens, M.D., principal clinical
coordinator for the West Virginia
Medical Institute’s new Health Care
Quality Improvement Program.
Following the keynote addresses at
both of these Lunch and Learn
programs, other visiting dignitaries
will join the speakers for panel
discussions.

Brief biographical information about
these three speakers begins below,
and registration details about these
luncheons are included on the WVSMA’s
Annual Meeting registration form
which appears on page 205. For more
details, contact Nancie Diwens at
(304) 925-0342.

Speakers highlighted

Dr. Woerth has been president of
her own medical management
consulting firm, J. K. Woerth, Inc.,
since 1986. She has presented over
450 seminars for state and local medical
societies, hospitals, and medical
specialty groups throughout the United
States, and has provided consultation
for private medical practices in 21 states.

In her consulting work, Dr. Woerth
assists physicians and their staffs in
maximizing third-party reimbursement,
improving patient payments through
better collection and billing techniques,
improving cash flow by reducing the
number of appeals made to Medicare
and other insurance carriers, increasing
office efficiency, reducing the chance
of punitive action from Medicare audits,

and developing personnel policy
manuals. In addition to her own
business, she is a staff associate with
Conomikes and Associates, Inc.

Dr. Woerth is a contributing editor
for the national Medicare publication
and also writes a monthly practice
management column for Missouri
Medicine. She regularly contributes to
medical publications in Michigan,
Florida and Maryland.

Dr. Woerth received her doctor of
philosophy degree in higher education
administration from the University of
Missouri in 1983- She also holds a
master’s degree in public health and
health administration from the
University of Oklahoma, a bachelor of
arts in sociology and a bachelor of
science degree in dental hygiene from
the University of Nebraska.

Dr. Weeks is a native West Virginian
who earned his bachelor of science
degree from West Virginia University
and his medical degree from the
University of Maryland School of
Medicine. After interning at Mercy
Hospital in Baltimore, Dr. Weeks
served as resident anesthesiologist at
Ohio Valley General Hospital in
Wheeling. Since 1956, he has been in
private practice, first in Clarksburg
and currently in Wheeling.

Lunch and Learn

During his career, Dr. Weeks has
been active in a wide range of health
care issues, including medical
economics, health insurance, medical
care foundations, health planning,
medical education and medical
licensure. Since 1973, he has been
president and medical director of the
West Virginia Medical Institute (WVMI),
and established himself as a national
leader in the fields of medical peer
review and health care quality
assurance. From 1968-76, Dr. Weeks
was the liaison between the medical
community and the governors of West
Virginia. He continues to serve as
health care resource person for
Senator Jay Rockefeller.

Since November 1992, Dr. Weeks
has been the project director for
WVMI’s External Peer Review Program
(EPRP) contract with the Department
of Veteran Affairs. In this capacity, he
oversees a nationwide medical data
abstraction and peer review program
that encompasses 171 of the nation’s
VA medical centers and 50,000
episodes of patient care a year. Under
Dr. Weeks’ direction, the EPRP has
become a national model for
independent quality assessment in a
multi-hospital system.

From 1977-80, Dr. Weeks served as
president of the American Association
of Professional Standards of Review
Organization. Dr. Weeks is also a past
president of the WVSMA, the West
Virginia Society of Anesthesiologists,
and the Ohio County Medical Society.
He has served as an AMA delegate for
the WVSMA, and as a member of the
Medical Licensing Board of West
Virginia. A fellow of the American
College of Anesthesiologists, Dr.

Weeks is also a diplomate to the
American Board of Anesthesiologists.

MAY 1994, VOL. 90 203

Dr. Stephens is a native of Madison,
W.Va., who earned his B.S. degree in
biology from the University of
Charleston in 1979, and his medical
degree from the Marshall University
School of Medicine in 1983- After
serving his residency in internal
medicine at West Virginia University’s
Charleston Division, Dr. Stephens was
named medical director of the
Charleston Area Medical Center’s Drug
and Alcohol Rehabilitation Unit.

In 1986, Dr. Stephens joined the
Charleston Medical Group, an internal
medicine practice. Two years later, he
began practicing family and internal

Radio Winners

medicine with Healthplus in Kanawha
and Putnam Counties, and also started
serving as a physician reviewer for the
West Virginia Medical Institute and as
an associate professor of medicine at
WVU's Charleston Division.

In August 1993, Dr. Stephens
accepted the position of principal
clinical coordinator for the WVMI’s
new Health Care Quality Improvement
Program (HCQIP). Under HCQIP, the
Health Care Finance Administration
shifted the focus of Medicare Peer
Review Organizations from identifying
individual episodes of substandard
care to addressing broad patterns of

The West Virginia Tobacco Control Coalition, of which WVSMA is a member, announced the
winners of its “Sound Off Against Tobacco Use” radio public service announcement contest
after receiving more than 1,100 entries from West Virginia students. Students in grades 5-12
wrote about either secondhand smoke or smokeless tobacco, and Philip Constantino of
Jefferson High School in Charles Town; Vickie Martin of John Marshall High School in Glen
Dale; Destiny Kelley of Taylor County Middle School in Grafton; and Aime Dizon of
Williamson Junior High School; were selected to come to Charleston to produce their PSAs
on West Virginia Public Radio. Chapman Printing Company donated certificates to recognize
these winners and all of the participants.

INTERPLAST seeking physicians, nurses

INTERPLAST WEST VIRGINIA, a
non-profit, volunteer organization of
plastic surgeons, anesthesiologists,
pediatricians, nurses and support staff
who travel to developing nations in
the Third World to perform free
reconstructive surgery on children
with cleft lips and palates, burns and
burn scar contractures, congenital
anomalies, and traumatic injuries, is
looking for new team members.

INTERPLAST currently has
programs set up in over 17 countries

throughout the world, and
INTERPLAST WEST VIRGINIA
sponsors two trips per year — one to
Ecuador and one to Peru. Teams
usually stay for approximately two
weeks and perform 120-150 surgeries.

For more information about the
program, phone (304) 291-5663 or
write to:

INTERPLAST WEST VIRGINIA
c/o David C. Fogarty, D.D.S., M.D.
165 Scott Ave., #206
Morgantown, WV 26505

care and working cooperatively with
hospitals and physicians to improve
these patterns. As principal clinical
coordinator, Dr. Stephens is overseeing
this new quality improvement effort in
West Virginia and is directly
responsible for implementing WVMI’s
“Cooperative Improvement Projects.”

A member of the American College
of Medical Quality and the American
College of Physicians, Dr. Stephens is
board-certified in internal medicine,
quality assurance, addictionology and
geriatrics. He has admitting privileges
at CAMC’s Memorial, General, and
Women’s and Children’s Divisions.

Surprise Birthday

Seated in a wheelchair with a quilt and
reading glasses, WVSMA Executive Director
George Rider hams it up with a bottle of
Metamucil, just one of the many gag gifts
he received at the surprise party for his
60th birthday, which was given by his
family and the WVSMA staff on April 5.

Save Your Life-
Stop Smoking

Call toll-freel-800-ACS-2345

AMERICAN

THERE’S NOTHING CANCER
MIGHTIER THAN THE SWORD ? SOCIETY

204 THE WEST VIRGINIA MEDICAL JOURNAL

The West Virginia State Medical Association’ s

August 17-20, 1994

The Greenbrier

White Sulphur Springs, West Virginia

V Sign Up NOW!

Please be sure to make hotel reservations in advance by calling 1-800-624-6070. The Greenbrier
will fill up quickly because the State Fair will be going on during the same week.

1994 Annual Meeting

Name

Conference Cost:

WVSMA member

$125

non-member

$175

Ar)dro<:«

Additional:

Citv State Zip Code

Thursday, Aug. 18

Learn and Learn

member/non-member

$40

Specialty

(CME Credit)

spouse/ student

$25

Phone

Friday, Aug. 19
Lunch and Learn

member/ non-member

$40

(CME Credit)

Payment by: Check Visa _ MasterCard

spouse/student

$25

TOTAL:

Card Number.

Expiration Date
Signature

If paying by check, please send registration form and check to:
West Virginia State Medical Association
P.O. Box 4106, Charleston, W V 25364

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Robert C Byrd Health Sciences
Center of WVU - Charleston

June 2

(Seminar) “ABCs of Caring for HIV-
Infected Patients,” Elizabeth A. Funk,
M.D.

June 16

(Seminar) “Pediatric Update,” Naser
Tolaymat, M.D.

June 21

(Seminar) “Management of Salivary
Gland Disorders,” (sponsored by The
Eye and Ear Clinic of Charleston and
the Dept, of Surgery), Robert E.
Pollard, M.D.

Robert C Byrd Health Sciences
Center of WVU - Morgantown

June 2-3

“The Spiritual Dimension of Illness,
Suffering and Dying,” (sponsored by
the WVU Center for Health Ethics
and Law)

West Virginia State Medical
Association - Charleston

June 25

Marbury v. Madison, Holiday Inn,
Clarksburg

June 28

1994 Medical Billing Seminar, Days
Inn, Flatwoods

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVTJ, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Gassaway □ Braxton County Memorial
Hospital, June 22, 6:30 p.m., “Diseases
of the Larynx,” James T. Spencer, M.D.

Oak Hill □ Plateau Medical Center,

June 28, 6:30 p.m., “Pediatric
Trauma,” A. Margarita Torres, M.D.

□ Plateau Medical Center, July 26,

6:30 p.m., “Lumbar,” Constantino Y.
Amores, M.D.

Logan □ Logan General Hospital, July 15,
11:45 a.m., “Trauma Resuscitation:
Optimizing in the Golden Hour,”
CAMC Trauma Services

Madison □ Boone Memorial Hospital,
June 14, 6:30 p.m., “Common
Dermatosis,” Donald Farmer, M.D.

□ Boone Memorial Hospital, July 12,
6:30 p.m., “Chest Trauma,” Frank C.
Lucente, M.D.

Man □ Man Appalachian Regional
Hospital, June 15, 6:30 p.m., “Diseases
of the Larynx,” James T. Spencer, M.D.

□ Man Appalachian Regional
Hospital, July 20, 6:30 p.m., “Medical
Evaluation of the Sexually-Abused
Child,” Kathleen Previll, M.D.

Montgomery □ Pleasant Valley
Hospital, June 23, noon, “New
Technologies in High-Risk
Obstetrics,” Norman Duerbeck, M.D.

□ Pleasant Valley Hospital, June 1,
12:30 p.m., “Lower Airway Illness in
Infants,” Felix R. Shardonosky, M.D.

Point Pleasant □ Pleasant Valley
Hospital, June 23, noon, “New
Technologies in High-Risk
Obstetrics,” Norman Duerbeck, M.D.

Point Pleasant □ Pleasant Valley
Hospital, July 28, noon, “Medical
Oncology,” Steven Jubelirer, M.D.

Richwood □ Richwood Area Medical
Center, June 9, 5:30 p.m.,
“Cryosurgical Ablation of the
Prostate,” James P. Tierney, M.D.

Ripley □ Jackson General Hospital,
June 10, 12:15 p.m., “Sinus Disease
and Surgery,” R. Austin Wallace, M.D.

Heart Attack.
Fight it with a
Memorial gift to
the American
Heart Association.

THE AMERICAN HEART
ASSOCIATION
MEMORIAL PROGRAM®

American Heart
1|JJf Association

This space provided as a public service.

206 THE WEST VIRGINIA MEDICAL JOURNAL

iee.di‘„« Poetry Corner y

June

5- 8-41st Annual Meeting of the Society of
Nuclear Medicine, Orlando

6- 7-Society for Vascular Surgery, Seattle

8- 12-Intemational College of Surgeons -
United States Section, Chicago

9- 11-Southem Association for Geriatric
Medicine, Hilton Head, S.C.

10- 11-Case Management and Utilization
Management in a Changing Healthcare
Environment (sponsored by the National
Association for Healthcare Quality, Kansas
City, Mo.)

10-12-American Congress of Rehabilitation
Medicine, Minneapolis, Minn.

16-17— 7th Annual Cardiology Symposium:
Clinical Cardiology Workshops (sponsored
by Ohio State University), Columbus
16-18-Bringing Rural Health and Managed
Care Together (sponsored by the National
Rural Health Association and the National
Center for Managed Health Care
Administration), Kansas City, Mo.

18-4th Annual Obstetrics and Gynecology
Clinical Update: Urogynecology and Female
Pelvic Floor Disorders (sponsored by Ohio
State University), Columbus
24-25-Communication Approaches for
Tracheostomized and Ventilator Dependent
Patients (sponsored by Voicing!, Inc.),
Chicago

26-29-American Orthopedic Society for
Sports Medicine, Palm Desert, Calif.

26-July 1— 7th World Conference on Lung
Cancer, Colorado Springs, Colo.

7- 8-Second International Conference on the
Varicella-Zoster Vims (sponsored by the
VZV Research Foundation), Paris

8- 9-Using Data to Improve Quality in
Healthcare (sponsored by the National
Association for Healthcare Quality), Houston

11-13-American In Vitro Allergy/
Immunology Society, Cambridge, Mass.
17-18-2nd Annual Alumni Symposium
Featuring the William H. Saunders
Lectureship (sponsored by Ohio State
University), Galloway, Ohio

August

5-6-Quality Improvement in Healthcare: An
Introduction (sponsored by the National
Association for Healthcare Quality), Chicago

8-10-American Hospital Association, Dallas

14-17-Midwest Surgical Association,
MacKinac Island, Mich.

25-27— Southern Association for Oncology,
Sea Island, Ga.

For More Information . . .

Contact the Journal at (304) 925-0342.

Ode to the Graduates

For the Medical Class of ‘94
Congratulations on the score.
Noting you 've been tested
As we 've suggested.

What was done or said
Was really not so bad.

Hope you forgave us
If we made you mad.

It was lies
When we criticized
Now recalling, youth
Was fine when it was mine !

Medicare and JCAHO
IPA, ISN’s, PPA and HMO
For these sets
We send regrets.

Lee L. Neilan, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward, M.D.,
Editor, West Virginia Medical Journal P. O. Box 4106, Charleston, WV 25364.

"to ^00 -HAdf am A^PotMTAktNT ?

MAY 1994, VOL. 90 207

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

Risk factor study
looks at health habits
of West Virginians

A survey of state adults shows West
Virginia has the nation’s lowest
prevalence of heavy alcohol drinking,
but the second highest incidence of
obesity. Information about these and
other health factors are included in
the 1992 Behavioral Risk Factor
Survey , recently released by the
Bureau of Public Health’s Office of
Epidemiology and Health Promotion.

This annual report presents data on
behaviors that can put people at risk
of preventable illness and death. These
factors include not using seatbelts,
hypertension, obesity, sedentary
lifestyle, cigarette and smokeless
tobacco use, and alcohol misuse.

More than 34% of adults in the state
reported being at least 20% over their
ideal weight, with only Mississippi
reporting a higher rate. Nearly 19% of
the men surveyed used smokeless
tobacco, and West Virginia ranked first
among the 13 states that rated its
prevalence. The data also showed 66%
of the state’s adults aren’t physically
active, 40% don’t use their seatbelts
regularly, and that 24% had high blood
pressure.

The state, though, is making
headway in reducing unhealthy habits.
While it does have a high smoking rate
of 24%, the prevalence of smoking has
fallen steadily over the nine years this
survey has been conducted. According
to questions about alcohol use during
the month previous to the interview,

2% reported having had 60 or more
drinks, 9% reported having had five or
more drinks on at least one occasion,
and 1% reported drinking and driving.

Survey results will be used to help
establish health policies and to monitor
the disease prevention efforts. For more
details or to obtain a copy of the
report, phone the Bureau’s Health
Statistics Center at (304) 558-9100.

State's breast, cervical
cancer rates increasing

The number of breast and cervical
cancer cases among West Virginia
women increased between 1991 and
1992, according to a report released by
the Bureau of Public Health. The West
Virginia Breast and Cervical Cancer
Incidence and Mortality Report for
1991-1992 examines the occurrence,
death rates and state of diagnosis of
breast and cervical cancer cases in the
state. This is only the second year
such data has been available.

For each 100,000 West Virginia
women, 90.1 were diagnosed with
invasive breast cancer in 1992, up
from 86.8 in 1991. The invasive
cervical cancer rate increased from
10.8 to 12.9 during the same time
period. These age-adjusted incidence
rates are based on data collected from
hospitals, laboratories, physicians,
clinics, the Bureau’s Vital Registration
Office and its Breast and Cervical
Cancer Screening Program, and from
the cancer registries in other states.

The age-adjusted death rate for
cervical cancer rose from 3-6 cases per

100,000 women in 1991, to 3.8 in 1992.
The latest available national data
shows West Virginia had the fifth worst
death rate from cervical cancer in the
United States from 1986 through 1990.
However, the age-adjusted death rate
for breast cancer fell to 24.7 per

100,000 women in 1992, down slightly
from 25-5 in 1991.

The report also showed early
diagnosis of breast and cervical cancer
rose in 1992 in many geographic areas
of the state. Early diagnosis of breast
and cervical cancer is extremely
important because these diseases can
be treated more easily and five-year
survival rates are greater.

This annual data collected by the
Bureau’s Cancer Registry will help
determine the best use of resources for
prevention and early detection of
breast and cervical cancer. The
information will also identify any
geographic areas where there is an
unusual occurrence of cancer.

To learn more about the report or the
Cancer Registry, contact Beverly Keener
at (304) 558-5358 or 1-800-423-1271.

Adolescent health
topic of new report

During a typical month in West
Virginia, seven adolescents will die as
a result of a preventable injury, 112
babies will be born to teens, 670
young people will start smoking, 341
teenagers will drop out of school and

84,000 of the state’s youth will go
without proper health care.

These are just a few of the statistics
that are contained in a a new report,
The Adolescent Health Profile , released
by the West Virginia Bureau of Public
Health’s Office of Maternal and Child
Health (OMCH). This report was
compiled by staff from the OMCH's
Adolescent Health Initiative, a new
program developed to improve the
health of West Virginians between the
ages of 10 and 17 years old. Since most
adolescent health problems result from
risk-taking behaviors, the program
promotes preventive health education,
especially on the community level.

Divided into 12 sections, this report
reveals statistics on areas such as
disease, reproduction, nutrition and
fitness, education and employment,
mental health, and health care finances.
Some of the findings are as follows:

•The state's rate of teen suicides is
16% lower than national rate.

•The state's rate of teen homicides
is 34% lower than the U.S. rate.

"■Automobile accidents account for
73% of all unintentional injury
deaths to adolescents in the state.

*Chronic or congenital illnesses
account for nearly 25% of all
deaths to the state’s youth.

‘More than 25% of all state high
school students are overweight or
obese, and only about half of
them regularly exercise.

*In 1992, more than 139,000 West
Virginians under the age of 21 were
eligible for Medicaid.

•From 1984-93, 20% of the state's
AIDS cases were people between
the ages of 20-29 who were
probably infected as teens.

For a copy of the report, call Nelson
Parker at (304) 558-3071.

208 THE WEST VIRGINIA MEDICAL JOURNAL

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YOCON

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5 4 mg of Yohimbine
Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration Yohimbine’s peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug. Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone

Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocon 5 is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.

Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history. Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.12 Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 '3'4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to % tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon’' 1/12 gr. 5.4 mg in

bottles of 100's NOC 53159-001-01 and 1000's NDC

53159-001-10.

References:

1. A. Morales et al. . New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed , p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,
1983.

4. A. Morales et al. . The Journal of Urology 128:
45-47, 1982.

Rev. 1/85

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Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Lasers being utilized
to remove tattoos,
birthmarks, liver spots

Tattoos, brown

)VV

Jacobsen there has been no

good method to
remove these,” Dr. Ellen Jacobsen,
adjunct assistant professor of derma-
tology said. “Argon lasers that were
introduced for this purpose several
years ago often had unsatisfactory
results. The treatment was painful, and
often the tattoo or birthmark was
replaced by a scar.

“That’s no longer the case. In the
last decade, there have been significant
advances in the technology available to
remove unwanted pigment from
human skin. It’s very exciting to have
these new lasers that can erase most
tattoos, port wine stains, liver spots
and superficial red blood vessels
painlessly, and without any lasting
scars,” Dr. Jacobsen added.

The lasers can be used safely on the
face — even around the eyes. It also
works very well on spidery red blood
vessels on the face.

New library dedicated
for Biochemistry

The Department of Biochemistry
recently dedicated the George H.

Wirtz Memorial Library, which was
created within the department in order
to keep faculty and students abreast of
the latest developments in the field.

George Wirtz, Ph.D., who died last
year, was a professor in the Department
of Biochemistry for 30 years.

Article written by
Antonelli published
in Academic Medicine

The March issue
of Academic
Mediae features an
article entitled
“ Practicing Physical
Evaluation Skills on
Community
Volunteers ,” by Dr.
Mary Ann Antonelli,
associate professor
of rheumatology.

Dr. Antonelli’s
article describes the reaction of
community volunteers who were the
subjects in a physical diagnosis
preceptorship.

Ferrari, Moore elected
to national task forces

Dr. Norman D. Ferrari, pediatric
clerkship director, and Dr. Renee
Moore, assistant pediatric clerkship
director, have been chosen to serve
on task forces for the national
organization of pediatric clerkship
directors.

Dr. Ferrari will be serving on the
evaluation task force and chair the
subcommittee on grading policy, and
Dr. Moore will be a member of the
faculty development task force. Their
appointments were made at the recent
meeting of the Council on Medical
Student Education and Pediatrics in
San Antonio, Texas.

Hornsby named ADA
board member

W. Guyton I fomsbyjr., Ph.D., C.D.E.,
assistant professor of exercise
physiology, has been nominated for a
three-year temi on the American
Diabetes Association Board of Directors.

In association with the ADA, Dr.
Hornsby has published "7he Fitness
Book. - For People with Diabetes. " Dr.
Irma Ullrich, professor of
endocrinology/metabolism, was a
contributing editor.

Post presents lectures,
authors chapter

Dr. William R.

Post, assistant
professor of
orthopedics,
served as a faculty
member at the
American Academy
of Orthopedic
Surgeons Winter
Sports Medicine
Post Course in Steamboat

Springs, Colo.

At the meeting, Dr. Post presented
lectures on arthroscopic knee meniscus
repair, diagnosis and treatment of
patellofemoral pain and instability,
arthroscopic repair for recurrent
shoulder dislocations, and new
concepts in tennis racket design and
their implications for players of all
levels.

In addition, Dr. Post recently
published a chapter on surgical
treatment of patellofemoral disorders
that appeared in a two-volume
textbook entitled "The Knee.” (Mosby
Co. 1994).

Gruen lectures at
orthopedics workshop

Thomas A. Gruen, M.S., adjunct
associate professor of orthopedics,
was a presenter at the “Contemporary
Topics in Orthopaedics” conference in
Sugarloaf, Maine from March 11-13-

Guen discussed radiographic
assessessment of osteolysis versus
stress-shielding with total hip femoral
components, and problems associated
with quantitative radiography in
orthopedics.

Landreth receives
Benedum award

Kenneth Landreth, Ph.D., professor
of microbiology/immunology, is one of
the four recipients of WVU’s 1994
Benedum Distinguished Scholar Award.

Dr. Landreth's Benedum lecture was
entitled “ Bone Marrow Lymphocyte
Production .”

210 THE WEST VIRGINIA MEDICAL JOURNAL

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Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

Hanshaw Center to
expand into major
geriatric institute

The Huntington Foundation has
pledged nearly $1 million to expand
Marshall’s Frank E. Hanshaw Sr.
Geriatric Center into a comprehensive
Geriatric Medicine Institute.

In announcing the 7-year, $932,800
grant, MU President ]. Wade Gilley
said the Huntington Foundation now
has donated more than $2.4 million to
Marshall.

“In 1988, the Huntington Foundation
made a visionary decision to grant $1
million to Marshall’s School of Medicine
to establish the Frank E. Hanshaw Sr.
Geriatric Center,” Gilley said. “Since
that time, the Hanshaw Center has
become a vital link in providing
services to the elderly. In addition to
providing geriatric medical care, the
center is at the forefront of geriatric
education and service coordination for
all of West Virginia and the mid-Ohio
Valley.”

Hanshaw will continue to focus
chiefly on comprehensive evaluation
services, although some patients still
will use the center as a source of
primary care, according to Dr. Shirley
Neitch of the School of Medicine who
will direct the center. Dr. Neitch said
the grant will enable the center to
expand its home-visit program and its
geropsychology, social work and
rehabilitation services, as well as
provide for prompt assessment of
patients referred by human service
agencies for urgent placement or
possible abuse situtations.

“An important component of our
plan to expand to a Geriatric Medicine
Institute is that we will begin to do
health services delivery research aimed
at developing ways to ‘export’ the
comprehensive assessment process to
outlying primary care practice sites,”

Dr. Neitch said. “What we do in
Huntington could be done by front-line
care providers if certain modifications

and educational efforts could be
initiated. Such a program would
require additional funding from other
resources, but would not be possible
at all without the Hanshaw Center as a
base,” she elaborated.

Demand also is expected to
increase for the services of Kathryn
Riley, M.D., West Virginia’s only
geropsychologist. Dr. Riley conducts
comprehensive, individually-tailored
neuropsychological test batteries upon
patients to determine whether their
cognitive abilities are impaired due to
a dementing disease such as
Alzheimer’s, or a “pseudo-dementia”
caused by depression or anxiety. As
the center's reputation has grown, an
increasing number of patients have
been referred to Dr. Riley for evalua-
tion and treatment of psychological
disorders such as depression, anxiety,
grief reactions, adjustment disorders,
and the psychoses.

The Geriatric Medicine Institute will
provide increased opportunities for
medical students, residents and
fellows. Marshall is intensely involved
with the state’s other medical schools
to obtain a federal grant to establish a
Geriatric Education Center for West
Virginia, Dr. Neitch said. “This will
primarily be a faculty education grant
which, through interface with the
Kellogg and Rural Health Initiative
training sites, will provide solid
geriatric education for a multitude of
care providers.

“As we head into the 21st century,
we anticipate continuing growth of
the elderly population, with many
experts estimating that fully 20
percent of the population will be over
65 years old. The Huntington Founda-
tion grant will allow us to address the
escalating need for geriatric care and
education,” Dr. Neitch added.

MU again earns
AAFP’s Silver Award

On May 2, Marshall again received
the Silver Achievement Award of the
American Academy of Family
Physicians for being one of the top
three U.S. medical schools in the
percentage of graduates entering
family practice residency programs.

marshaliMJniversity

The AAFP initiated the Family
Practice Percentage Award program
two years ago to honor LCME-
accredited medical schools that have a
high percentage of graduates who
enter ACGME-accredited family
practice residency programs over the
preceding three-year period.

For the 1991-1993 period, Marshall
had 27.7 percent of its graduates
entering family practice residencies, a
percentage topped only by Mercer
University School of Medicine and the
University of North Dakota School of
Medicine. Twelve medical schools
received bronze awards for averages
between 20 percent and 24.9 percent.

Nine grads honored
at commencement

Nine graduating medical students
received the following awards during
commencement activities for the
School of Medicine:

Dr. Caroline B. Miller - The Bertha
and Lake Polan Award for the
student with the highest academic
standing, and also the Upjohn
Achievement Award for being the
graduate who faculty members
believe represents the highest
attributes of physicianhood.

Dr. Cris R. Richardson - The

CIBA-Geigy Award for the graduate
who, in the opinion of his peers,
exemplifies the ideal physician.

Dr. Robert A. Barnabei - The

Bettye and Albert Esposito Award
(community service).

Dr. Michael L. Meadows - The W.

Edwin Black Award (family practice).

Dr. Michael J. Maroney - The

Fuller Albright Award
(endocrinology).

Drs. G. Marshall Lyon III and
Bradley J. Richardson - The

Cardiology Award.

Dr. Patricia J. Wilson - The

Gastroenterology Award.

Dr. Kimberly A. Oxley - The

Thomas G. Folsom Award
(pediatrics).

212 THE WEST VIRGINIA MEDICAL JOURNAL

Free Inpatient Treatment Program

For Schizophrenia or Schizoaffective Disorders

Highland Hospital is offering a free treatment program for acute exacerbation of
chronic schizophrenia or schizoaffective disorder using an investigational medication.

Interested candidates must be healthy males or females from 18 to 65. Females must
be sterile or using acceptable birth control. Candidates must be willing to give
informed consent and agree to a four-week hospital stay.

If the treatment is effective, the candidate may continue outpatient treatment with
the medication for one year at no cost. There is no charge for the inpatient or
outpatient programs.

For more information,

Contact: Charles C. Weise, M.D., (304) 925-2159.

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Medical
Student News

We are more than “just” medical students

Dear Fellow Medical Students:

Let me start by reminding everyone that the WVSMA Medical Student Section offers us the perfect opportunity to
become a visible and active influence in the future of health care. Since we will be practicing physicians within the
next few years, our suggestions for improving health care both at the state and national level system are vital.

Thanks to the work of previous Executive Council members, the WVSMA-MSS has a solid foundation and now
it is up to us to help continue their outstanding efforts. I hope the MSS will grow even stronger this year through
increased membership and expanded programs, and I want all members to feel they have an equal opportunity to
take part in our organization.

At this time, I want to list all of this year's officers and encourage you to contact me or any of the other officers
to express your opinions and ideas:

Executive Council Huntington

President Dave Faber Mary Marcuzzi

Vice President Nick Cottrell Teresa Duncan

Secretary/Treasurer Lisa McAvey Tony Aprea

*The Charleston Division of WVU officers will be determined in July.

Information is the name of the game, and our organization offers many ways of obtaining this knowledge. Find
out all you can about health care and the issues surrounding it by attending state and national conferences, becoming
involved with your communities, and interacting with political leaders. I would also like to see each of the component
societies increase their participation. This is the one of the most effective ways of keeping everyone informed about
current issues that may affect us as individuals and our future as a whole.

At our Executive Council meeting in April, we were able to plan our agenda for this year. One of the most important
decisions we made was to create an indepth survey that would be sent to all medical students. Once the results are
tabulated, we plan to publish them in the Journal and present them to members of the West Virginia Legislature.

In closing, I would like to extend my sincere t hanks to each of you for allowing me to represent you as the president
of the Executive Council of the WVSMA-MSS and ask you to always remember this thought: We are more than “just”
medical students, we are future physicians, we are in the system, and we have a voice.

David C. Faber, MS III
WVSMA-MSS President

Morgantown

Linda Burstynowicz
Missy Matulis
Kristin DeHaven

P.S. PLEASE MARK YOUR CALENDARS NOW AND PLAN TO ATTEND OUR NEXT COUNCIL MEETING ON
JULY 23 AT THE WVSMA OFFICE IN CHARLESTON!!!

214 THE WEST VIRGINIA MEDICAL JOURNAL

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Obituaries

Carl E. Johnson, M.D.

Dr. Carl E. Johnson, 93, of Charlotte,
N.C., formerly of Morgantown, died
March 20 at Presbyterian Hospital in
Charlotte.

Dr. Johnson was born in Davis, and
after graduating from high school in
1918, he was in the student army
training corps at Washington and Lee
University. He then attended WVU,
where he received a bachelor of arts
degree in 1924 and a bachelor of
science degree in 1925. He obtained
his medical degree from Northwestern
University Medical School.

Following his internship at Harper
Hospital in Detroit, Dr. Johnson opened
his office in 1928 at the Monongahela
Building in Morgantown, the address
which he kept for the duration of his
46-year practice. A respected member
of Morgantown’s medical community,
Dr. Johnson was known for his
24-hour-a-day commitment to his
patients. He was a family practice
physician who specialized in pediatrics,
and during the early part of his career
he delivered babies. Often he was
paid for his services with produce,
chickens or other forms of barter.

Dr. Johnson administered the first
polio vaccine in Monongalia County on
April 18, 1955; and until he retired from
practicing in 1974, he made house calls.

“House calls are valuable tools in
treating patients,” Dr. Johnson had once
said. “I’d have the opportunity to see
from the homes if the patients were
happy, getting along all right, or
possibly having a hard time
economically, all factors which affect
recovery.”

During his career, Dr. Johnson was
chief of staff at Monongalia General
Hospital and St. Vincents Pallotti
Hospital. He was also a clinical
associate professor at WVU and was
on the staff of the WVU Medical Center
Hospital. In addition, Dr. Johnson was
a medical advisor for Head Start of
Monongalia County and for Selective
Service Local Board 14, as well as a
medical examiner for C & P Telephone
Company.

Dr. Johnson was president of the
Monongalia County Medical Society in
1942 and served as secretary from
1940-42. A member of the WVSMA
Council for nine years, Dr. Johnson
also served on several WVSMA
committees. A fellow of the American
College of Physicians since 1943, Dr.

Johnson was also a member of the
AMA, West Virginia Pediatric Society,
and the boards of the Morgantown
Hospital Association, Medical Surgical
Services and Valley Counseling Services.

After he retired in 1974, Dr. Johnson
became president of the Monongalia
General Hospital Foundation from
1976-1986. At a 1992 Monongalia
General Hospital and Morgantown
Orthopedic Associates’ tribute, Tom
Senker, president and CEO of
Monongalia General, described Dr.
Johnson as “the epitome of a scholar,
a professional and a gentleman.”

Dr. Johnson is survived by his wife
of 67 years, Lillian Posten Johnson;
one son, Carl Edward Johnson Jr. of
Charlotte; one daughter, Mrs. Jennifer
Johnson Firestone of East Bernard, Vt.;
and four grandchildren.

Donations can be made to the
Foundation of Monongalia General
Hospital Inc., 1200 J. D. Anderson
Drive, Morgantown, WV 26505.

John H. Kilmer, M.D.

Dr. John Henry Kilmer, 84, of
Martinsburg, died February 10.

Dr. Kilmer was a graduate of
Martinsburg High School, West Virginia
University, and Thomas Jefferson
Medical College in Philadelphia. He
served his internship at the Ohio
Valley General Hospital in Wheeling,
and the Lutheran Hospital in Fort
Wayne, Ind. He completed his
residency at Columbia Hospital for
Women in Washington, D.C.

Dr. Kilmer was a well-known
obstetrician and gynecologist in
Martinsburg for over 35 years, who
retired from private practice in 1976.
During his career, he also served as
plant physician for E.I. DuPont and
Corning Glass Works; as physician for
Norborne Nursing Home; and as the
coroner for Berkeley County.

Actively involved in community
affairs, Dr. Kilmer setved as president
of the Berkeley County PTA, the
Eastern Panhandle West Virginia
University Alumni Association and St.
John’s Lutheran Church Council. He
also was instrumental in the
establishment of the Panhandle Home
Health Association.

Dr. Kilmer was a retired colonel
from the U.S. Army Reserve. He served
on active duty in the European Theater
with the U.S. Medical Corp during
World War II, receiving the Silver Star,

216 THE WEST VIRGINIA MEDICAL JOURNAL

the Bronze Star, two Purple Hearts,
the Combat Infantryman’s Badge,
three Arrow Heads and the African
Campaign Ribbon with seven stars.

Dr. Kilmer was a fellow of the
American College of Obstetricians and
Gynecologists. In addition to being a
member of the WVSMA, he was a
member of the AMA, the Eastern
Panhandle Medical Association, Phi
Kappa Psi fraternity, and St. John’s
Lutheran Church, Martinsburg.

Survivors include two sisters, Eva
Lee Plunkett and Katherine Bush, both
of San Antonio, Texas; two sons, John
H. Kilmer Jr. and Wade C. Kilmer, both
of Martinsburg; four daughters, Judith

K. Kilmer of Martinsburg, Patricia G.
Anderson of Tucson, Ariz., Fredrica H.
Meitzen and Katherine K. Powell, both
of Morgantown; two grandsons, Derek

L. Kilmer and Jacob P. Powell; two
granddaughters, Heather K. Kilmer and
Tecca R. Kilmer; and several nieces and
nephews. He was preceded in death
by his wife, Dorothy Dammeier Kilmer.

Memorial contributions can be
made to St. John’s Lutheran Church,
Queen Street, Martinsburg.

Society News

McDowell

The members began their March
meeting will a special expression of
appreciation to Dr. Charles Michaelis
for all of his outstanding work as
secretary-treasurer over the past few
years.

Dr. Herland shared a letter from the
Welch Chamber of Commerce
requesting funds for Project Graduation.
The members then voted to make a
donation to the three county high
schools, as the society had done in
previous years.

In other new business, Dr. Herland
urged all members to support the
WVSMA with their dues and
contributions. At his suggestion, the
members also approved sending a
letter to the Tug River Health
Association, congratulating them on
the formal dedication of their new
satellite clinic in Northfork. In
addition, Dr. Michaelis announced
that a notice had been put in the local
newspaper about the society’s new
Speakers Bureau.

BALTIMORE

MARYLAND
i LIB.-flCQ
:NE STREET

: 1201

Volume 90 No. 6

West Virginia State Medical Association

DEPT

Did The Door
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EDITOR

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MANAGING EDITOR

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EXECUTIVE DIRECTOR

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ASSOCIATE EDITORS
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(ISSN 0043-3284) is published monthly by
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West Virginia Medical

OURNAL

Contents

Feature Article

Knowledge of medical changes 226

Scientific Newsfront

Differential diagnosis of wide QRS tachycardias 232

Results of cancer information assessment of
high school students in West Virginia 235

Staphylococcus aureus: A continuing problem

(Medical Grand Rounds from the Robert C. Byrd Health

Sciences Center of WVU) 238

President’s Page

Making a difference 242

Editorial

WESPAC - Now more than ever 243

Intercepted Mail 244

Special Departments

General News 246

WVSMA Annual Meeting Registration Form 249

Continuing Medical Education 250

Medical Meetings/Poetry Corner 251

Bureau of Public Health News 252

Robert C. Byrd Health Sciences Center of WVU News 254

Marshall University School of Medicine News 256

Alliance News 258

New Members/WESPAC Members 259

Obituaries 260

Classified 26l

June Advertisers 262

Front Cover

The beautiful Sandstone Falls area of the New River
National Park in Summers County. Photo courtesy of
Stephen J. Shaluta Jr., West Virginia Division of Tourism
and Parks.

JUNE 1994, VOL. 90 225

Knowledge of medical charges

ROBERT E. JOHNSTONE, M.D.

Professor, Department of Anesthesiology,
Robert C. Byrd Health Sciences Center of West
Virginia University, Morgantown

CINDY L. MARTINEC, Ph.D.

Assistant Professor, Department of
Management, College of Business and
Economics, West Virginia University,
Morgantown

Abstract

Ignorance of medical charges by
decision-makers could handicap
cost control programs. By written
survey, we determined the ability
and confidence of 267 adults,
including 85 health care tcorkers, to
estimate four medical charges:
epidural anesthesia for childbirth,
outpatient hernia surgery,
dipyridamole-thallium heart stress
test, and a one month supply of
nicotine drug patches. Only 36% of
the estimated charges fell within
50% of the actual charges for the
four medical services. Accuracy did
not differ among physicians, non-
physician healthcare workers and
consumers; estimates varied greatly
with many being extremely low or
high. Respondents rated medical
charges significantly more difficidt
to estimate than non-medicaL
Seventy percent of respondents felt
that most physicians do not know
enough about medical charges to
give good advice and 92% felt that
they did not know enough about
medical charges to make
satisfactory choices.

Introduction

Consumers and providers generally
agree that health care is expensive
and requires reform. Cost control
proposals include elements of rationing,
competition, allocation of global
budgets, group alliances and improved
practice efficiency. All these proposals
depend on decision-makers having
sufficient knowledge of medical costs
to make rational economic decisions,
and past studies (1,2) and current
reports (3,6) reveal ignorance of
medical charges.

To further understand the current
limits of medical charge knowledge,
we surveyed 267 consumers and
providers in the Morgantown health
care market.

Methods

To conduct our research we tested
two hypotheses:

1. Most people can estimate charges for
medical services and goods within
50% of their actual values; and

2. No difference exists between
perceived difficulty of estimating
medical and non-medical charges.
We surveyed a stratified sample of

adults with a written questionnaire
with the following four sections:

(1) Knowledge of medical charges;

(2) Knowledge of non-medical
charges;

(3) Opinions; and

(4) Personal data.

A. Epidural anethesia for childbirth
C. Dipryridamole-thallium heart stress test

The first section asked respondents
to estimate the charges for each of the
four following medical services or goods
at West Virginia University Hospital:

(1) Epidural anesthesia for childbirth
(anesthesiologist, supply and drug
charges);

(2) Surgery as an outpatient for hernia
repair without complications
(surgeon, anesthesia and hospital
charges);

(3) Heart stress test as an outpatient
using dipyridamole-thallium; and

( hospital and doctor charges); and

(4) A one-month supply of nicotine
patches (drug only).

These services and goods were
described to identify all components
of the final charge, and the last
question in this section asked the
respondent to rate on a scale of 1 to 10
the ease (1) or difficulty (10) of
estimating these four medical charges.

B. Outpatient hernia surgery

D. A one-month supply of nicotine drug patches

ACTUAL

CHARGE

ID *0

.I i i

ESTIMATED ANESTHESIA CHARGE ($)

Figure la. Distribution of charge estimates for:

226 THE WEST VIRGINIA MEDICAL JOURNAL

The second section of the survey
asked respondents to estimate charges
associated with the following four
non-medical services:

(1) Minimum in-state tuition for a full-
time undergraduate engineering
student for one semester;

(2) Usual fees of a local certified
public accountant to prepare a
1040 form without additional
schedules;

(3) Usual fees for a local lawyer to
prepare a simple will without trust
forms; and

(4) The monthly charge for local basic
cable television service.

As in the first section, the final
question asked the respondent to rate
the ease (1) or difficulty (10) of
estimating these four non-medical fees.

The third section asked if the
respondent thought that most physicians
knew enough about medical charges
to give good advice to patients, and if
the respondent knew' enough about
medical charges to make satisfactory
choices. The last section requested the
individual to give his/her age,
occupation and highest education
level completed.

Implementation and analysis

Attendees at a medical grand rounds,
anesthesia grand rounds, bioethics
conference, undergraduate business
lecture, elementary school teachers
conference and civic club meeting, as
wrell as shoppers at a local mall, were
asked to complete the survey. General
information, but no price clues, were
provided concerning the survey.

Respondents had unlimited time to
complete the survey and could skip
questions they w'ere unable or
unwilling to answer. Mall shoppers
completing the survey received a
university pen and pencil. Actual
medical values wrere determined by
interviewing the clerks who enter
medical charges into the computerized
billing systems for the hospital and
medical practice, and they were then
confirmed by directors of the various
departments. Actual bills from 10
patients undergoing dipyridamole-
thallium heart stress tests were
randomly selected on 10 different
days to validate reported charges.
Non-medical values were determined
by a telephone survey of local lawyers
and accountants, and by contacting
appropriate officials at WVU and

cable television offices. Estimates by
respondents were analyzed and
reported with descriptive statistics.

The hypothesis concerning accuracy
of charge estimation would be rejected

if less than 50% of the responses fell
within 50% of the actual charges.
Rejection of the hypothesis concerning
perceived difficulty of estimating
medical versus non-medical charges

z 20

ACTUAL

CHARGE

I..

o *0 10<x> KXX) 3000 *000 5000 0000 7000 8000 9000 Ai , 10 000

ESTIMATED SURGERY CHARGE ($)

Figure lc.

JUNE 1994, VOL. 90 227

was determined by a significant
difference between the Likert scale
rankings using the Mantel-Haenszel
chi-square test.

Results

The total number of surveys
returned with answers was 267.
Approximately 15 people read the
survey and declined to provide any
answers, usually saying it was “too
difficult." Thirty -two percent of the
respondents worked or studied in the
health care field and seven percent
did not list their occupation. Those
respondents who were in a health-
related field included physicians,
medical technicians, nurses, medical
students, administrators, and ancillary
hospital staff.

The ages of all respondents ranged
from 18 to 79, with 83% falling
between 18 and 45. In addition, 13%
of those answering the questionnaire
had not gone to college, 57% were
college graduates, 11% had master’s
degrees, 4% had doctorate degrees,
and 15% had medical degrees.

Actual charges

The actual total charge for a
dipyridamole-thallium cardiac stress
test, $1,977, was determined by
adding seven separate charges
together. These charges included $78
for thallium, $365 for dipyridamole,
$714 for imaging, $125 for the
radiologist, $133 for the cardiologist,
$493 for the stress lab, and $69 for
computer usage.

Examination of the 10 patients
receiving dipyridamole-thallium heart
tests showed only six had received all
seven charges. Three patients were
missing charges for dipyridamole, one
for the radiologist, and one for the
stress lab. Two patients had additional
charges which apparently originated
during the stress testing; one for
consultation and one for an
electrocardiogram. Excluding the
additional charges, the average
amount actually charged patients was
$1,783- No clerk, technician or
physician interviewed during this
process correctly stated all seven
charges consistently.

Analyses

Estimated charges varied greatly,
and the mean responses and actual
values for each charge estimated are
given in Table 1. The mean estimates
exceeded the actual values for the
epidural anesthesia and the nicotine
drug patches by 131% and 35%, but

fell below the actual values for the
hernia surgery and the dipyridamole-
thallium heart stress test by 49% and
61%.

Health care workers and physicians
were not more successful than non-
health care respondents in estimating
charges. Figure 1 shows bar graphs of
the distributions of charge estimates
for the four medical procedures. The
percentages of responses falling
within 50% of the actual values are
shown in Table 2. Overall, only 38%
of medical charge estimates were
within 50% of actual values, which
proved our first hypothesis was
incorrect.

Examination of charge estimates
using different criteria for accuracy or
outliers consistently showed a great
variation of estimates, and that
respondents could not estimate the
medical charges as well as the non-
medical. For instance, only 18% of
respondents overall estimated the
medical charges within ± 20%,
whereas 32% estimated non-medical
charges within this range.

Opinions

On a scale of 1-10, respondents
rated medical charges significantly
more difficult to estimate than non-
medical charges (8.1 ± 2.0 versus 5.7
± 2.1, p < 0.05). Seventy percent of
respondents, including all physician

respondents, felt that most physicians
do not know enough about medical
charges to give good advice to
patients.

Ninety-two percent of respondents
felt that they did not know enough
about medical charges to make
satisfactory choices. No differences
among respondents by age or
educational level were detected.

Discussion

Since health care is so expensive
and its costs are increasing so fast,
system reform is often justified on this
basis alone. Many proposals exist and
they all address costs through many
different mechanisms (7). One
proposal advocates “savings from
small-market reforms” (8), and
President Clinton has advocated “a
restructured set of ground rules that
foster competition to provide the best
care at the best price” (9).

Both of these strategies, as well as
most other cost-control proposals,
depend on the knowledge of charges
by decision-makers. If the decision-
maker is the patient, then success
depends on his or her ability to shop
for the best deal. If the decision-
maker is the physician or another
health care agent, then this advisor
must select effective products and
services from treatment options with
varying costs. For either process to

ACTUAL

CHARGE

ESTIMATED DRUG CHARGE ($)

Figure Id.

228 THE WEST VIRGINIA MEDICAL JOURNAL

Table 1. Characteristics of Medical and Non-Medical Charge Estimates

Service

Mean + SD

Min

Max

Actual

Anesthesia

253

S793 ± 1,037

$20

$10,000

$344

Surgery

254

$2,218 ± 1,940

$150

$15,000

$4,323

Heart test

251

$767 ± 1,639

$15

$20,000

$1,977

Drug

254

$149 ± 160

$20

$1,500

$110

Tuition

259

$1,748 ± 1.488

$450

$10,000

$1,049

Tax

259

$134 ± 118

$15

$700

$75

Will

258

$209 ± 180

$10

$1,150

$75

262

$26 ± 9

$10

$100

$22

succeed, the decision-maker must
know the costs of, as well as have
access to, all the medical goods and
services under consideration.

This study found that a diverse
group of West Virginia physicians,
health care workers, and consumers
could not estimate locally prevailing
medical charges. Many were
uncomfortable even trying. No
individual respondent came within
50% of the actual value on all four
medical charge questions, and many
respondents gave estimates far
removed from the actual values.

Health care purchasers who estimate
too low may feel cheated when
discovering the actual charge, and
consumers who estimate too high may
not pursue needed medical services,
or may pay too much for what they
obtain. The frustration of many
respondents estimating charges was
epitomized by one who left some
answers blank and said “I just don’t
have a clue.” It is also surprising that
not one of 40 physicians, after trying
to estimate the four medical charges,
thought that physicians knew enough
about charges to give good advice.

This study has many limitations
since the survey involved only one
locality, did not cover all medical
goods and services, and the
respondents did not represent all
demographic groups. Costs at a
university hospital are higher than at
many community hospitals, and the
surveyed Morgantown residents may
have a different awareness of prices
than in other communities. This study
also does not show that ignorance of
medical prices is damaging or causes
cost control programs to fail. Perhaps
the respondents, in real-life situations,
could find the necessary price
information since some insurance
companies and consulting groups are
now building financial databases and
selling this information. Prices may
not even be important in a system
where insurance companies or large
payers have enough clout to decide
what is paid. However, the ignorance
of prices and frustration were so
profound that they appear to be real
problems.

Another limitation of this study is
the fact that it does not determine the
reasons why people have so little
knowledge of medical prices. One
reason could be that the general
public has difficulty understanding

medical terms, so weighing medical
treatments, even without considering
cost, is confusing. Physicians may
require specialty consultations to
differentiate technical procedures.
Once the medical procedures are
understood, there is frequently
confusion over whether hospital costs
or patient charges are more pertinent,
and over which goods and services
are charged together. What is a
comprehensive charge in one hospital
may be broken apart or grouped
differently in another hospital. There
are few national standards for
charging and each locality develops
their own systems.

Bundling or separating charges are
each justifiable and promote different
kinds of fairness, but the diversity
makes acquiring price knowledge
difficult. Consent forms which
describe medical procedures and risks
in detail seldom include costs, so
neither physicians nor patients learn
or consider this economic fact. In
addition, more than one legal (billing)
entity may deliver one apparent
service. As found in this study, several
physicians and hospital departments,
each presenting separate bills, were
involved with one dipyridamole-
thallium stress test, and the different
departments were not sure what the
others charged.

It is obvious that the system of
identifying, entering and accumulating
medical charge data and presenting
medical bills is so intricate that errors
occur and charges can vary among
patients for the same treatment. Thus,
it can be extremely difficult to
determine total charges for a specific
treatment, and even a sophisticated
hospital has difficulty billing them
consistently.

Who should bear the responsibility
for health care cost containment —
consumers, providers, payers or
regulators? A global determination that
neither medical nor non-medical

Table 2. Percentages of Charge

Estimates Falling Within 50%
of the Actual Charge

Service

Within 50%

Anesthesia

Surgery

Heart test

Drug

Medical Average

Tuition

Tax

Will

■TV

Non-Medical Average 59

populations could estimate medical
charges accurately would be alarming
and might drive cost-containment
efforts in a direction that neither
physicians nor patients desire. Until
the extent and meaning of price
ignorance are known or other
answers to expensive health care are
found, cost simplification and
education deserve emphasis, and by
themselves could constitute reform.

References

1. Nagurney JT, Braham RL, Reader GG.
Physician awareness of economic factors in
clinical decision-making. Med Care 1979;
17:727-36.

2. Robertson WO. Costs of diagnostic tests:
estimates by health professionals. Med Care
1980;18:556-9.

3. Rose Jr. The cost of care? Many patients
haven't a clue. Med Econ 1993 (Feb 22); 12.

4. Ruffenach G. Firms use financial incentives
to make employees seek lower health-care
fees. Wall Street J 1993 (Feb 9);Bl-6.

5. Diamond GA. Doctors' estimates of U.S.
health care spending. N Engl J Med 1993;
328:1202.

6. Johnstone RE, Martinec CL. Costs of
anesthesia. Anesth Analg 1993;76:840-8.

7. Blendon RJ, Edwards JN, Hyams AL. Making
the critical choices. JAMA 1992;267:2509-20.

8. Sullivan LW. The Bush administration’s
health care plan. N Engl J Med 1992;327:
801-4.

9- Clinton B. The Clinton health care plan. N
Engl J Med 1992;327:804-7.

JUNE 1994, VOL. 90 229

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Differential diagnosis of wide QRS tachycardias

JOHN H. LOBBAN, M.D.

STANLEY B. SCHMIDT, M.D.

LARRY A. RHODES, M.D.

ABNASH C. JAIN, M.D.

Sections of Adult and Pediatric Cardiology,
Robert C. Byrd Health Sciences Center of WVU,
Morgantown

Abstract

This article reviews new criteria
for distinguishing ventricular
tachycardia from supraventricular
tachycardia with aberrancy.

Introduction

A rapid arrhythmia with wide QRS
complexes is either ventricular
tachycardia or supraventricular
tachycardia with aberrant ventricular
conduction. It can be difficult to
distinguish between these possibilities,
but proper therapy hinges on a correct
diagnosis.

Older criteria for differentiating
between these two conditions included
complex morphologic features, which
were difficult to apply and often not
reliable (1). Recently, a simplified
stepwise approach has been
advocated (2), and this article reviews
our experiences with two cases in
which we utilized this new approach.

First case report

A 64-year-old woman presented with
palpitations and chest pain. She had

an old anteroapical myocardial
infarction, and past cardiac
catheterization showed an occluded
left anterior descending artery. The
ejection fraction was 24%. She did not
appear to be distressed.

This patient’s pulse was 150 beats/
minute and the blood pressure 125/70
mmHg. After an EKG (Figure 1), she
was given procainamide I.V., which
slowed the rate to 129 beats/minute,
but did not affect the QRS morphology.
The mechanism of the tachycardia
remained unclear, and an
echocardiogram was performed,
which was interpreted as showing 1 : 1
association between atrial and
ventricular contraction. Based on this
observation and the absence of
hemodynamic instability, a diagnosis
was made of supraventricular
tachycardia with aberrant ventricular
conduction.

Later, this patient was electrically
cardioverted and underwent
electrophysiologic (EP) testing. This
reproduced her arrhythmia and
confirmed the mechanism as ventricular
tachycardia. She was successfully
treated with intraoperative mapping
and resection of her arrhythmia focus.

Second case report

A 58-year-old man presented with
palpitations and near syncope. He was
confused and had a systolic blood
pressure of 70 mmHg. His EKG is
shown in Figure 2, and physicians
thought he was in sustained ventricular

tachycardia, so he was electrically
cardioverted to normal sinus rhythm.

Subsequent work-up revealed a
normal echocardiogram, normal
treadmill exercise test with thallium
imaging, and the presence of dual
atrioventricular (AV) nodal pathways (3)
at EP study. During this study, this
patient was also inducible into sustained
AV nodal reentrant tachycardia, which
was accompanied by aberrant
ventricular conduction having a left
bundle branch morphology. His EKG
during this arrhythmia was identical to
the one that had been obtained when
he first came to the emergency room.
He elected to try medical therapy
before catheter ablation, and has done
well on verapamil 240 mg/day.

Misconceptions

Several misconceptions about wide
QRS tachycardias appear to be rather
commonly held in the medical
community (Table 1). Of these, probably
the most prevalent is that a
hemodynamically stable patient with a
good blood pressure cannot be in
ventricular tachycardia. This is a false
assumption, which can lead to
prolonged delays in appropriate therapy.

In our experience, it is not rare to
see patients with monomorphic
ventricular tachycardia who tolerate
their arrhythmia well for hours or
even days and have only mild
symptoms. Conversely, it is not rare
for supraventricular tachycardias to
present with hypotension, as illustrated

FIGURE 1. The EKG of the patient in Case 1.

232 THE WEST VIRGINIA MEDICAL JOURNAL

TABLE 1. Misconceptions About Wide
QRS Tachycardias

1. A normal blood pressure is very strong
evidence for a supraventricular
mechanism.

2. A 1:1 association between ventricular
and atrial activity proves a
supraventricular mechanism.

3. A right bundle branch block QRS
morphology strongly favors a
supraventricular mechanism.

4. Sustained ventricular tachycardia almost
never occurs in young healthy patients.

5. Verapamil is safe to give as a routine
diagnostic and therapeutic intervention.
[Each of these statements is false.]

by our second case. Pulselessness
favors a ventricular mechanism, but
otherwise the blood pressure is of
little use in distinguishing ventricular
from supraventricular tachycardia.

Physicians have been trained to
look for independent atrial activity
“marching through” the ventricular
rhythm during wide QRS tachycardias.
This “AV dissociation" remains a very
useful diagnostic observation, and if
found, essentially proves that the
arrhythmia is ventricular tachycardia.
Unfortunately, AV dissociation is not
very sensitive, and is recognizable on
the surface EKG in only about 20% of
cases of proven ventricular tachycardia
(2). Less widely appreciated is the fact
that half of the cases of ventricular
tachycardia have 1 : 1 conduction from
ventricles to atria through the AV
node, producing AV association. AV
association, therefore, does not establish
a diagnosis of supraventricular
tachycardia, as shown by our first case.

Older criteria for the differential
diagnosis of wide QRS tachycardias
relied heavily on detailed analysis of
QRS morphology (1). Although these
criteria can still be helpful, they can
also produce misleading results, and
are often difficult to remember. Contrary
to some perceptions, the mere presence
of a right bundle branch block pattern
during tachycardia does not by itself
favor a supraventricular tachycardia
mechanism, since about two-thirds of
cases of ventricular tachycardia also
follow this pattern (1).

Young and middle-aged patients
without a history' of heart disease who
present with wide QRS tachycardia
are often assumed to have a
supraventricular arrhythmia. Frequently,
however, this is not the case. Several
disease processes and arrhythmia
mechanisms can lead to ventricular
tachycardias in this population, and

one should not be persuaded by the
patient’s age and past history to
prematurely exclude the possibility of
a ventricular arrhythmia.

Idiopathic ventricular tachycardia in
these patients is often exercise-induced,
and in about half of cases shows a left
bundle branch block morphology with
a normal or rightward axis. The latter
arrhythmia generally originates in the
right ventricular outflow tract (4). It can
be successfully treated with catheter
ablation, although most of our patients
have opted for medical treatment and
have remained essentially asymptomatic
on beta-blocker therapy.

A final misconception about wide
QRS tachycardias is that verapamil
should be used as a drug of choice
for both diagnostic and therapeutic
purposes. This practice is not as
frequent as in the past, but is still
encountered. The danger of this
approach is that verapamil often
causes hemodynamic collapse when
mistakenly given to patients with
previously tolerated sustained
ventricular tachycardia. Adenosine (6
mg. I.V. push) has a much shorter
duration of action than verapamil, and
should be used instead when a
therapeutic trial is considered warranted.
In unclear situations, the Advanced
Cardiac Life Support guidelines call for
an initial trial of lidocaine (1-1.5 mg/kg
I.V. push) before trying adenosine (5).

New diagnostic criteria

In response to the perceived
limitations of earlier diagnostic criteria,
Brugada and colleagues sought to
define a more accurate method for
diagnosing wide QRS tachycardias.
They developed a four-step algorithm
(Figure 3) which we have found
helpful and easy to apply.

The first diagnostic step is to
examine the precordial (V) leads of
the EKG. If none of these shows an
RS complex (R wave followed by an S
wave), the diagnosis of ventricular
tachycardia is highly probable. If one
or more RS complexes are present,
one proceeds to the next step, which
involves measurement of the longest
R to S interval present in these leads.
This interval is measured from the
onset of the R wave to the nadir of
the S wave (Figure 4). If this exceeds
100 ms. in any V lead, it argues strongly
in favor of ventricular tachycardia. If
neither of these two criteria is positive,
one proceeds to apply older criteria in
a stepwise fashion, looking first for
AV dissociation, and if necessary,
examining details of morphology.

Applying these criteria in a
prospective sample of wide QRS
tachycardias, Brugada and his
colleagues found a 98% correct
classification rate. All of their patients
with supraventricular tachycardia and
aberrancy had an RS complex in at

SVT = supraventricular tachycardia, VT = ventricular tachycardia. VI -2 = VI orV2. From
Brugada et al. (2). Used with permission of the publisher.

FIGURE 3- Stepwise approach to differential diagnosis.

JUNE 1994, VOL. 90 233

The R to S interval is measured in the precordial (V) leads from the onset of the R wave to the
deepest part of the S wave. A value > 100 ms. in any V lead strongly favors ventricular
tachycardia. Example is from Case 1 (lead Vi).

least one precordial lead, and 26% of
their ventricular tachycardias lacked
an RS in any of these leads, giving the
first criterion modest sensitivity but
high specificity for ventricular
tachycardia.

We have also found their second
criterion (R to S interval) particularly
useful. In the Brugada series, none of
the patients with aberrancy had an
interval > 100 ms., while 52% of
ventricular tachycardia patients had an
RS longer than 100 ms. in one or
more V leads. Again, this criterion
shows a moderate sensitivity for
ventricular tachycardia with a high
specificity. As expected, they found
the third criterion (AV dissociation) to
be highly specific for ventricular
tachycardia, but detected it in only
21% of their ventricular tachycardia
patients. If the fourth criterion
(morphology) was applied, they
required the morphology in both
leads V] (or V2) and V6 to support a
ventricular mechanism, otherwise, a
diagnosis was made of supraventricular
tachycardia with aberrancy. Their
morphologic criteria excluded older
features such as QRS axis and width,
as these were found to have a poor
diagnostic specificity.

This algorithm leads to a correct
diagnosis in both of the cases we
presented. The first patient had an RS
interval of 145 ms. on her initial EKG,
pointing to the correct diagnosis of
ventricular tachycardia. The second
patient fulfilled none of the criteria for
ventricular tachycardia (longest RS =

70 ms.), and would thus be labeled as
having supraventricular tachycardia
with aberrancy.

Finally, it remains necessary to
“look at the patient,” and consider the
overall history. About 85% of all wide
QRS tachycardias in adults are due to
ventricular tachycardia (6). This
percentage is probably even higher in
patients with coronary disease and
prior myocardial infarction. In spite of
these odds, there is sometimes a
reticence to diagnose ventricular
tachycardia, even when this has been

FIGURE 4. Measurement of R to S interval.

proven to be the cause of previous
arrhythmia episodes. When all else
fails, one will be correct more often
than not in diagnosing a wide QRS
tachycardia as ventricular tachycardia
in a patient with known coronary
disease.

Summary

This article has reviewed the
differential diagnosis of wide QRS
tachycardia. We have found the
stepwise approach suggested by
Brugada to be very useful. Of the
newer criteria that he proposes, the R
to S interval of > 100 ms. appears to
be a particularly helpful clue favoring
the diagnosis of ventricular tachycardia.
Hemodynamic stability, young age,

1:1 AV association, and the absence of
structural heart disease do not exclude
a diagnosis of ventricular tachycardia.
Most wide QRS tachycardias in adults
are ventricular, and when all else fails,
one will be right more often than not
in favoring this as the diagnosis over
supraventricular tachycardia with
aberrancy.

The R to S interval is measured in
the precordial (V) leads from the

onset of the R wave to the deepest
part of the S wave. A value >100 ms.
in any V lead strongly favors
ventricular tachycardia. Example is
from Case 1 (upper tracing is VQ.

References

1. Wellens HJ, Bar FW, Lie KI. The value of
the electrocardiogram in the differential
diagnosis of a tachycardia with a widened
QRS complex. Am J Med 1978;64:27-33-

2. Brugada P, Brugada J, Mont L, et al. A new
approach to the differential diagnosis of a
regular tachycardia with a wide QRS
complex. Circulation 1991;83:1649-59.

3. Janse MJ, Anderson RH, McQuire MA, Ho SY.
“AV nodal” reentry: Part I: “AV nodal”
reentry revisited. I Cardiovasc Electrophys
1993;4:561-72.

4. Mont L, Seixas T, Brugada P, et al. The
electrocardiographic, clinical, and
electrophysiologic spectrum of idiopathic
monomorphic ventricular tachycardia. Am
Heart J 1992;124:746-53.

5. Emergency Cardiac Care Committee and
Subcommittees, American Heart Assocation.
Adult advanced cardiac life support. fAMA
1992;268:2199-2241.

6. Steinman RT, Herrera C, Schuger CD,
Lehmann MH. Wide QRS tachycardia in the
conscious adult: ventricular tachycardia is
the most frequent cause. JAMA 1989;26l:
1013-6.

234 THE WEST VIRGINIA MEDICAL JOURNAL

Results of cancer information assessment of high
school students in West Virginia

STEVEN J. JUBELIRER, M.D.

Director of the Cancer Care Center of
Southern West Virginia, Charleston Area
Medical Center ;• and Clinical Professor of
Medicine, Robert C. Byrd Health Sciences of
WVU, Charleston Division

MARY F. BLANTON, M.Ed.

Adjunct Assistant Professor, Department of
Community Medicine, Robert C. Byrd Health
Sciences of WVU, Charleston Division
JAY ZHANG, Ph D.

Biostatician, Charleston Area Medical Center

DANIEL FOSTER, M.D.

Clinical Professor, Department of Surgery,
Robert C. Byrd Health Sciences of WVU,
Charleston Division
JODY MONK, R.N.

Charleston Area Medical Center
BRENDA JONES, B.A.

Charleston Area Medical Center
DEBBIE HANSHEW, B.A.

Charleston Area Medical Center
MARIA RAY, R.D.

Charleston Area Medical Center

Abstract

The “Just Say KNOW To Cancer"
education program was implemented
in public high schools in Kanawha
County, W.Va., to assess students’
knowledge of cancer risk factors
and to provide an educational
program about cancer prevention .
An anonymous questionnaire was
completed in two urban and six
suburban schools by 1,235 students
in their classrooms. The responses
revealed that only 35% and 10% of
students were able to identify two or
more risk factors and one American
Cancer Society warning sign,
respectively. Tobacco was the most
commonly identified risk factor,
being listed by 64% of urban
students, compared to 50% of
suburban respondents (p < .001).
Although 84% of all students
correctly answered the question
regarding the medical complications
of smokeless tobacco, only 39%
correctly answered the question
relating second-hand smoke as a
cancer risk factor. The results of
this study indicate the need for
cancer education in the high school
health curriculum.

Introduction

An estimated 74 million Americans,
30% of the present U.S. population,
will eventually develop cancer (1). In

addition, cancer is the second leading
cause of death for children and the
fourth leading cause of death for
adolescents (2).

Using data and estimates from Doll
and Peto (3), seven cancer risk factors
have been identified by Iverson and
Scheer (4) that seem to be the most
applicable to educational intervention
and ultimately, behavior change. These
risk factors are identified as tobacco
use, alcohol use. diet, reproductive
and sexual behavior, pollution,
radiation and sunlight.

Since children and adolescents are
at a stage in life where health attitudes
and behaviors are being developed,
cancer education programs should
obviously be implemented in the
school system (5). The “Just Say
KNOW To Cancer "education program
was implemented in public high
schools in Kanawha County, W.Va.,
for students ages 14-17 to assess their
knowledge of cancer risk factors and
to provide an educational program
about cancer prevention which

focuses on causes and biology of
cancer, substance use, nutrition and
eating patterns, and early detection.
This article provides the results of this
cancer information assessment.

Methods

Ninth and 10th grade students
(N = 2,010) in the Kanawha County
public schools who were enrolled in
either health or biology classes in the
1989-90 school year were asked to
complete the “Just Say KNOW To
Cancer ” student questionnaire. This
study was designed to obtain a
baseline of the student’s knowledge of
cancer risk factors, cancer warning
signs (as cited by the American Cancer
Society), and cancer prevention and
screening methods. The questions were
presented in multiple choice, true/false,
and open-ended listing formats.

Initial contact with each school was
made with the school principal by the
coordinator of the study who was
based at Charleston Area Medical
Center. The principals were asked to

Figure 1. Cancer Risk Factors Identified

•64.1%

Risk Factors

* The difference between city & surburban schools is significant (p < .10)

JUNE 1994, VOL. 90 235

select a “health teacher contact” for the
classes involved. The questionnaires
were designed to be self-administered
in a 15-minute period and returned to
the health teacher contact. This
teacher contact subsequently placed
the anonymous questionnaires in a
self-addressed envelope and returned
them to the study coordinator.

Results

Completed questionnaires (N = 1,235,
or 63%) were received from eight
schools (two urban and six suburban).

In response to being asked to list as
many as four possible cancer risk
factors, only 36% of students were able
to identify more than one risk factor.
One risk factor was identified by 64%
of the students, two by 23%, three by
1 1%, and four by 2%. The average
number of risk factors identified by the
urban students (x = 1.39) was
significantly higher than the average
number identified by the students in
the suburban schools (x = 0.99)

( Wilcoxon Rank Test, z = 5.55, p < .001 ).

While all cancer risk factors were
identified more frequently by students
attending the urban schools than by
those attending suburban schools
(Figure 1), there were significant
statistical differences in the risk factors
of tobacco use, sunlight exposure,
alcohol use, and limited exercise.
Tobacco was the most commonly
identified risk factor, being correctly
listed by 64% of urban students, as
compared to 50% of suburban
respondents (x 2 = 33 92, p < .001).
Diet, hereditary factors, and early
sexual activity were the second, fifth,
and sixth most frequently identified
cancer risk factors by this sample,
respectively; and while all were more
commonly listed by urban students
than by suburban students, the
differences were not statistically
significant.

Although 84% of all students
correctly answered the question
regarding the medical complications

of smokeless tobacco use, only 39% cancer risk factor (Figure 2). In
correctly answered the question addition, only 10% of the students

relating second-hand smoke as a were able to list more than one

Figure 2. “Just Say Know To Cancer” Student Questionnaire

Percent of Students With Correct Answers

Overall

Urban

Surburban

Students

1. Cancer is a disease that:

a) starts in several locations of the body
at the same time.

b) is usually caused by an infection

c) is caused by abnormal cell growth.

d) is fatal in most cases. 46

2. Metastasis is:

a) a type of cancer.

b) a new cancer treatment.

c) a term that describes the way a
cancer spreads.

df a phase of cell growth. 28

3. The largest single preventible cause of
death and disability in this country is:

a) drunk driving.

b) cigarette smoking.

c) suicide.

d) heart disease. 39

34**

4. The regular use of smokeless tobacco can cause:

a) receding gums.

b) wearing of enamel.

c) oral cancer.

d) bad breath.

e) all of the above. 84

82**

5. Second hand smoke:

a) is called active smoking.

b) contains poisonous gases.

c) is of no concern, since smoking only
affects the person inhaling.

d) can cause emphysema and bronchitis,

but has no correlation to lung cancer. 39

6. Which of these foods are highest in fiber?

a) cheeseburger.

b) pinto beans and cornbread.

c) pizza.

d) lettuce salad. 56

7. Which is the more healthy lunch?

a) chicken patty on bun with special sauce
and cola.

b) plain hamburger w'ith mustard, catsup, pickle

and 2% milk. 75

72**

8. Which contains less fat?

a) milkshake.

b) frozen yogurt. 88

* Preferred Answer • • Statistically significant at .05 level

Table 2. Percent of Students Who Identified American Cancer

Society Warning Signs

Sign

* Rank

Change in bowel or bladder habits

3.3

Sore that does not heal

Unusual bleeding

4.7

Thickening or lump in breast or elsewhere

28.2

Indigestion or difficulty in swallowing

0.5

Obvious change in wart or mole

5.2

Nagging cough or hoarseness

10.0

* Percentage ranking among 33 signs listed by at least five students

Table 1. Ten Most Frequently Listed Warning Signs

Sign

Percent

Lump

28.2*

Pain

19.2

Sleepiness/fatigue

11.9

Nagging cough

10.0*

Vomiting

9.5

Shortness of breath

8.6

Rashes

6.1

Loss of hair

5.8

Change in wart/mole

5.2*

Diseases

5.1

236 THE WEST VIRGINIA MEDICAL JOURNAL

cancer-related warning sign of the
American Cancer Society’s warning
signs; and of the seven warning signs
identified by the American Cancer
Society, only 25% of the students
could identify one and just 10% could
name two or more.

Overall the students listed 97
different warning signs, and of the 10
most frequently listed warning signs
(Table 1), only three (lump, nagging
cough, and change in wart or mole)
coincided with the ACS warning signs
(Table 2).

Discussion

Several studies have indicated that
scientifically accurate knowledge of
cancer risk factors and prevention is
not commonplace among children
and adolescents.

In 1977, a survey by Charlton of
3,537 adolescents who were ages
11-18, found that although 89%
mentioned smoking as a cause of
cancer, more than half mentioned no
other cause (6). Two years later, a
study entitled the National Adolescent
Student Health Survey (7), asked 8th
and 10th grade students about the
effect of too little fiber in their diets.
Sixteen percent stated colon cancer
would result from too little fiber in
their diet, 17.9% stated high blood
pressure would be an effect, 6.4%
gave a response of heart problems,
and 59-4 % did not know any
outcomes that would result from a
low-fiber diet.

In our study, only 36% of the
students identified more than one risk
factor (i.e., smoking, diet, etc.), and
only 10% identified more than one
cancer warning sign. In addition, only
2.4% of students listed frequent sexual
activity as a risk factor for cancer. This
latter finding is noteworthy since West

Virginia has a higher than average rate
of cervical cancer mortality in the
United States (8). In addition, 6l% of
the students were generally unaware
that second-hand smoke was
considered a cancer risk factor, but
this may be due to the fact that data
concerning the dangers of second-
hand smoke has only recently been
provided to the public by the
scientific community.

The authors noted apparent
confusion by the students with their
understanding and use of the terms
“warning signs” and “risk factor” as
evidenced by examples of the
warning signs frequently listed; pain,
sleepiness/fatigue, vomiting and
rashes. Examples of risk factors listed
were heart murmur, hair loss and low-
weight.

Much of the cancer education in the
schools has been an outgrowth of
American Cancer Society’s programs.
Due to the heterogeneous nature of
the American school system, it has
been difficult to measure the quantity
and quality of these programs.
Nevertheless, a variety of cancer
education and evaluation programs
directed toward the adolescent
population have been developed,
including the School Health Curriculum
Project (9), the Know Your Body
Program (10), and Project Choice (11).
All of these prevention-oriented
curricula have been extensively
evaluated and found to be successful
in modifying students’ knowledge,
attitudes and behavior.

The “Just Say KNOW to Cancer"
project has provided the first cancer
education program and assessment
questionnaire for adolescents in West
Virginia. This questionnaire was
designed to maximize validity by
volunteer participation and the

assurance of anonymity. Major
limitations of this study include the
absence of post-program knowledge
assessment and involvement of a
limited student population (i.e. only
9th and 10th grade students), but the
results clearly indicate the need for
cancer education in high schools in
the state.

Acknowledgement

The authors would like to thank
Paul Blanton, Ph.D., and Shawn
Chillag, M.D., for their editorial review
of this manuscript.

References

1. Cancer Facts and Figures. Atlanta (GA):
American Cancer Society; 1991.

2. Boring CC, Squires TS, Tong T. Cancer
statistics, 1993. CA-Cancer J Clin 1993;43:7-26.

3. Doll R, Peto R. The causes of cancer:
quantitative estimates of avoidable risks of
cancer in the United States today. New
York, Oxford University Press, 1981.

4. Iverson DC, ScheerJK. School-based cancer
education programs: an opportunity to
affect the national cancer problem. Health
Values 1982;6(3):27-35.

5. D’Onofrio CN. Making the case for cancer
prevention in the schools. I Sch Health
1989;59(5):225-31.

6. Charlton A. Cancer: opinions of some
secondary school pupils in Northern
England. Int J Health Ed 1977;20:112-8.

7. Portnoy B, Christenson GM. Cancer
knowledge and related practices: results
from the National Adolescent Student
Health Survey. J Sch Health 1989;55:214-17.

8. National Cancer Institute: Cancer Statistics
Review 1973-1989. Bethesda (MD): U.S.
Department of Health and Human Services.
NIH Publication No. 92-2789, 1992.

9. Green LW, Heit P, Iverson DC, et al. The
School Health Curriculum Project: its
theory, practice and measurement of
experience. Health Educ Q 1980;7(l):14-34.

10. Wynder EL. Primary prevention of cancer.
The case for comprehensive school health
education. Cancer 1991;67:1820-3.

11. Iammarino NK, Weinberg AD. Cancer
prevention in the schools. J Sch Health
1985;55(3):86-95.

JUNE 1994, VOL. 90 237

Medical Grand Rounds

Robert C. Byrd Health Sciences Center of WVU

Edited by Irma H. Ullrich, M.D., Professor of Medicine, Section of Endocrinology and Metabolism

Staphylococcus aureus: A continuing problem

JEFFREY L. NEELY, M.D.

Associate Professor of Medicine, Section of
General Internal Medicine, Robert C. Byrd
Health Sciences Center of WVU, Morgantown

Abstract

Caution is required in managing
any immunocompromised host, not
only because these patients will be
carriers, but because they are also
very susceptible to infections with S.
aureus. These hosts are not
candidates for short-course
antibiotic therapy, and catheters
should be removed when S. aureus
bacteremia is diagnosed. The S.
aureus cell wall is a major
determinant of the host response
and the pathogenicity of this
organism. The clinician should
recognize the three most important
toxins produced by S. aureus:
exfoliatin, TSST-1, and enterotoxin-R
Toxic shock syndrome can occur in
any host, not just menstruating
females, and the clinician should be
very thoughtful when dealing with any
Staphylococcus aureus infections
arising from the use of a catheter.

Introduction

Staphylococcus aureus is an
innovative microbe that is truly, as
Sheagren described it 10 years ago,
the “persistent pathogen” (1). Along
with E. coli, it is one of the most
commonly acquired hospital
infections, and the toxins produced by
this pathogen are numerous, with
new ones discovered yearly.

S. aureus is well equipped to invade
minor skin breaks, protect itself from
host defenses, reach the blood stream
and cause endocarditis or metastatic
infections, all the while producing
toxins in picogram quantities which
cause diseases with extreme
consequences. This organism also has
enormous adaptive capabilities as
evidenced by its history.

This paper presents a case that
demonstrates many of the basic science

and clinical principles needed to deal
with this pathogen. The current
literature regarding catheter-associated
bacteremia, several relevant clinical
infections, methicillin-resistant
Staphylococcus aureus will also be
reviewed.

Patient presentation

A 40-year old male presented to the
Outpatient Clinic at Ruby Memorial
Hospital on July 22, 1993, with nausea
and abdominal cramping pain that
had been present for eight hours. He
had experienced similar symptoms
two weeks previously, as well as a
fever with bloating and gas, but he
thought these conditions were related
to symptoms his preschool children
were having at the time. His past
medical history was significant only
for a paronychia the previous month
which had been treated with an oral
cephalosporin.

This patient appeared very ill, curled
on the exam table with abdominal
pain. The vital signs showed him to

be orthostatic and his temperature
rose from 37.2°C to 38.5°C within the
hour. The chest exam was clear, and
the cardiac exam revealed a grade I/VT
systolic ejection murmur without
radiation. The abdomen was diffusely
tender with a few tinkling bowel
sounds. Tenderness was variable, but
he actually developed rebound
tenderness while in the clinic. The
rectal exam was negative, and the
skin showed no rashes or cellulitis.

Significant laboratory values showed
WBC= 13,000 with no left shift,
hemoglobin of 14.8 gm/dl, and a
normal urinalysis. Since there was
abdominal pain, fever and rebound
tenderness, a CT scan of the abdomen
was perfonned (Figure 1). It showed
multiple hepatic defects consistent with
abscesses, and the patient was begun
on broad spectrum antibiotics
including oxacillin (Prostaphlin)® and
metronidazole (Flagyl)®.

A CT-guided aspiration of the liver
lesions revealed blood-tinged fluid,
and the stains showed a few PMN’s

1056 02 61 Oi
Image

jMHTOn PL!

hNTEP I OF',

Figure 1. CT scan of the abdomen showing a cross-sectional view of the liver. This
demonstrates multiple defects (arrows) which on biopsy revealed polycystic liver disease.

238 THE WEST VIRGINIA MEDICAL JOURNAL

and no organisms. Cultures of this
fluid were negative, but blood cultures
drawn on the day of admission grew
Staphylococcus aureus within 48 hours.
This patient was considered clinically
recovered after a difficult eight-week
course of clindamycin (Cleocin)®, but
the CT scan of his abdomen showed
no change in the liver lesions.

Laproscopic surgery revealed
multiple “blue-lake” lesions on the
surface of the liver which produced
straw-colored fluid when they were
punctured. Cultures of this fluid were
also negative, but biopsy of these
lesions showed multiple epithelial-
lined cysts consistent with polycystic
disease of the liver. The clinical
impression was that the patient became
bacteremic from the previous
paronychial infection, which seeded
one of the liver cysts that subsequently
burst, causing a S. aureus peritonitis.

Epidemiology

The history and the epidemiology
of S. aureus are inextricably intertwined.
In the 1950s, there was a pandemic of
serious S. aureus infections following
in the wake of resistant organisms.
These serious infections occurred in
hospitals which had selection pressures
on the staphylococcal organisms
(because of the widespread use of
antibiotics), large numbers of susceptible
patients and good carriers (doctors
and nurses).

The key to understanding the
epidemiology of S. aureus is knowledge
of the carrier state (1). The carrier state
is usually defined as a positive swab
from the nares, axilla or perineal region;
and 30% of health care workers will
have S. aureus cultured from the
anterior nares.

From the nose, the organisms spread
to the skin where they may survive for
two days (2). Some may be persistent
carriers in the perineal or axillary
region; persons with abnormal skin
are not only carriers but also launch
showers of bacteria-laden epithelial
cells into the air (3). Transmission by
airborne particles and fomites plays
little role; and once heavy droplets
reach the floor, they usually do not
redisperse. Transmission from person
to person is thus not an easy process,
but dependent upon a susceptible host.

The classic susceptible hosts are
persons with atopic dermatitis or
eczema (4); and those using needles
including diabetics, addicts, allergy
and hemodialysis patients (1,5-7).
Newborn infants are extremely
susceptible to colonization with

staphylococcal organisms, as are patients
receiving corticosteroids and those with
foreign bodies such as skin sutures or
plastic catheters (8). The identical
organism carried in the nares of a
susceptible host will cause his/her
systemic disease; e.g. endocarditis.

Microbiology

Staphylococci are divided into three
clinically important species: S. aureus
which produces coagulase and DNAase;
S. epidermidis; and S. saprophyticus
which is significant because of its role
in producing urinary tract infections in
young women.

The typical grape cluster appearance
on Gram’s stain is a consequence of
random cell division in three planes.
Daughter cells stick because
staphylococci are covered with a
carbohydrate surface that forms
intercellular bridges, linking the cells
into clusters (2).

This reaction may also play a role
in the disease process, especially in
catheter-related S. aureus infections.
The cell wall is composed of
unbranched, linked glycan chains
cross linked with pentapeptides. This
produces a rigid cell-wall polymer
called peptidoglycan which enables
the organism to survive in harsh osmotic
environments; elicit pyrogen; attract
PMN’s; activate complement; and elicit
opsonic antibodies (9).

The other two major components of
the cell wall are Protein A and teichoic
acid. Teichoic acid is probably
important for attachment to mucous
membranes, but measurement of
teichoic acid antibody has not proved
to be clinically useful. Lysozyme (found
in tears and saliva) and B-lactam
antibiotics are both active at the
pentapeptide crosslinks.

Extracellular enzymes and toxins
produced by staphylococci are
numerous. The enzymes include
catalase, coagulase, hyaluronidase,
lipases and nuclease (10). The
extracellular toxins include alpha and
beta toxin which damage cell
membranes or degrade sphingomyelin.
Important toxins are exfoliatin,
enterotoxin B, and toxic shock
syndrome toxin- 1 (TSST-1).

Host determinants also play a major
role in staphylococcal disease (11).
Adhesion of the staphylococcal
organisms is the first important step
and it occurs in nasal mucosal cells,
endothelial cells during septicemia,
and disrupted skin. Next, the host
invades by penetrating the epithelial
or mucosal surface; the classical clinical

presentation is the patient who develops
S. aureus pneumonia after an influenza
virus has damaged the pulmonary
epithelium, allowing invasion of the
staphylococcal organisms.

Chemotaxis must be intact in the host
for ingestion and killing of the
staphylococcal organisms; Job syndrome
and Chediak-Higashi syndrome are
the clinical settings in which patients
develop recurrent S. aureus infections
because of defective chemotaxis of
the host PMN’s. Rheumatoid arthritis
and decompensated acidotic diabetes
mellitus are diseases predisposed to
staphylococcal infections because of
acquired chemotactic defects.

Opsonization also plays an important
role in host defense; peptidoglycan
and Protein A trigger the complement
system so that S. aureus is coated with
C3 and IgG. There are no specific
opsonization defects that predispose
to S. aureus infections. Intracellular
killing, if defective, allows recurrent S.
aureus infections and is seen in patients
with chronic granulomatous disease
and lymphoblastic leukemia (11).

A major host determinant
predisposing to S. aureus infections is
the presence of a foreign body. The
predisposition is thought to occur for
three reasons: S. aureus is known to
produce glycocalyx in the presence of
a foreign body (protective slime);
phagocytic cells in the area of foreign
bodies become incapable of killing;
and S. aureus organisms anchor to the
fibronectin/fibrinogen complex
covering the foreign bodies (8).

Clinical subsets

Skin infections may be separated
into localized infections without a rash
and skin infections associated with a
rash (significant toxin production).
Common skin infections include
folliculitis, furuncles, carbuncles, and
impetigo.

Mastitis caused by S. aureus may be
a problem for nursing mothers (10,12).
Hidradenitis suppurativa is often
caused by S. aureus, and S. aureus
wound infections are a serious threat
to post-operative patients, especially
those receiving orthopedic appliances.

The staphylococcal skin infections
associated with significant toxin
production are more menacing.
Exfoliatin and TSST-1 are the most
significant toxins in these clinical
problems. Staphylococcal scalded skin
syndrome occurs when certain strains
of S. aureus produce epidermolytic
exotoxins (exfoliatin is the best
described) that lead to large bullae
and separation of epidermis resulting

JUNE 1994, VOL. 90 239

in areas of denuded skin. The toxin is
thought to disturb the adhesion of cells
in the stratum granulosum. The process
starts abruptly with a sunburn-like,
tender rash which spreads to the entire
body. In two to three days, bullae
appear and then near total
desquamation occurs. Gentle friction
on apparently healthy skin will cause
it to wrinkle and be displaced
(Nikolsky’s sign). These patients are
managed as burn patients with
appropriate antibiotics and fluids (10).

Toxic shock syndrome was first
described in menstruating women, but
it should be considered in all other
patient populations since it can be seen
in any clinical scenario where S. aureus
is involved (13). This clinical syndrome
is thought to be the result of production
of the toxic shock syndrome toxin- 1
I (TSST-1) by certain strains of S. aureus.

It is often described as a “superantigen”
, due to the fact that it can stimulate
release of tumor necrosis factor,
interleukin-2 and other cytokines in
picogram quantities. Along with a
blanching erythematous, deep red
rash and hypotension, these patients
also suffer with intense myalgias,
fever, vomiting, diarrhea and mucous
membrane inflammation.

Bacteria

The incidence of gram-negative
bacteremia has remained stable, but S.
aureus bacteremia has risen dramatically
in small non-teaching hospitals.
Methicillin resistant S. aureus (MRSA)
community-acquired bacteremic
infections among intravenous drug
abusers has also increased significantly
(14).

S. aureus bacteremia relates strongly
to host susceptibility. The three major
risk groups are among patients with
defective defenses (diabetes mellitus,
PMN defects such as Job syndrome,
eczema, transplant recipients, cancer
patients, and AIDS patients), patients
with catheters or foreign bodies, and
intravenous drug abusers.

There are three critical questions
that should be asked when dealing
with S. aureus bacteremia:

1. Which patients will develop
endocarditis?

2. Which patients will develop
metastatic infections?

3. How long should patients be
treated with antibiotics?

The risk of subsequent endocarditis
is reported to vary from 10% to 60%.
Nolan and Beaty (15) showed that
there are three major risks that
predispose a staphylococcemic patient

to endocarditis: an absent primary focus
of infection; community acquisition; and
presence of metastatic sequelae. The
increased risk for endocarditis in these
clinical subsets is probably explained
by the lack of an early diagnosis.

In Nolan’s study, 57% of the patients
who had no primary focus and also
had a community acquisition of the S.
aureus infection developed endocarditis.
Metastatic sequelae were a weaker risk
since 24%-50% of the staphylococcemic
patients had metastatic infections
without having infective endocarditis.
Echocardiographic demonstration of
valvular vegetations strongly predicts
infective endocarditis in patients with
S. aureus bacteremia, but Bayer (16)
showed that by combining the three
risk criteria previously mentioned with
the echocardiographic presence of
vegetations, the sensitivity of diagnosing
infective endocarditis increased from
70% to 85% with a 100% specificity.

The decision to perform
echocardiography on patients with
S. aureus bacteremia can be
strengthened by these clinical
indicators, but no studies to date have
given us the definitive answer.

Cather-related bacteremia

In an excellent review of catheter-
related infections, Raad (8) described
the four most important sources for
colonization of venous catheters as
skin insertion site, catheter hub,
hematogenous seeding, and infusate
contamination. The skin insertion site
and the catheter hub are by far the
two most common sources.

Topical antibiotics, disinfectants,
and silver or dacron cuffs decrease the
rate of colonization, but plastic
transparent dressings increase the rate.
The catheter hubs are contaminated
from the organisms carried on the hands
of health care workers. Hematogenous
seeding is described, but rarely seen,
and infusate contamination usually
occurs in epidemics.

Adherence of the bacteria is the key
step in the pathogenesis of catheter-
related infections. In reaction to a
foreign body, the host produces a
biofilm composed of thrombin, fibrin
and fibronectin while S. aureus
produces glycocalyx (slime). Together
these entities enhance adherence of
the organisms and protect the
embedded organisms from antibiotics,
PMN’s and antibodies (8). The type of
catheter material is also important
since organisms adhere to
polyvinylchloride better than Teflon
(17). The complications of catheter-
related infections include metastatic

infections, abscesses, septic emboli,
endocarditis, fatal sepsis, septic
thrombosis, and the problems and
expense of inserting a new catheter.

There are two pertinent clinical
questions in the management of
catheter- related S. aureus bacteremia:

1. Should the catheter be removed?

2. What is the length of antibiotic
therapy?

Raad and Bodey (8) feel that proper
management depends on the extent
of the infection (local or systemic), the
microorganism involved, the type of
catheter (surgically implantable or
percutaneous non-tunnelled), and the
clinical status of the host.

Most authors now agree that the
catheters must be removed in all cases
of S. aureus catheter-related bacteremia.
There is no disagreement that the
catheter must be removed if the patient
remains febrile for 72 hours after
antibiotics are started, if there is
persistent bacteremia, or if tunnel pus
can be demonstrated (8,10,18). Dugdale
and Ramsey have shown that for
Hickman-related S. aureus bacteremia,
there is an increased incidence of
sepsis-related death if the catheter
remains (18). In addition, Raad also
recommends removal of the catheter
in any immunocompromised host (8).

Length of therapy is also an
important question. One quarter of
these patients have complications and
one in seven dies. The conventional
wisdom was that patients with
catheter-related S. aureus bacteremia
should receive 4-6 weeks of antibiotic
therapy because of presumed
concomitant infective endocarditis.
Ehni and Reller (19) studied two weeks
of therapy and found that there was a
20% overall complication rate; and
that 9% of patients developed infective
endocarditis, and 1 1% developed a
metastatic infection.

Ehni and Reller felt that the following
factors may indicate that short-course
therapy is appropriate:

1. Removal of the catheter at the
time of diagnosis of bacteremia.

2. Absence of valvular heart disease.

3. Rapid defervescence with
antibiotic therapy.

4. Lack of immunosuppression.

5. Administration of a full 14-day
course of antibiotics.

Jernigan and Farr also reviewed
short-course therapy in 1993 (20). They
suggested that “the optimal duration
of treatment remains unknown” and
that randomized trials were required
to draw a valid conclusion (20).

240 THE WEST VIRGINIA MEDICAL JOURNAL

Staphylococcus aureus can infect any
organ system. The incidence of S.
aureus as the infective agent in surgical
series and in spontaneous bacterial
peritonitis is reported to be around 10%
(21), but S. aureus is the most common
infective agent in patients undergoing
continuous ambulatory peritoneal
dialysis (83% in many series) (22).

Staphylococcal pneumonias can be
separated into the two clinical categories
of either inhalational or hematogenous.
There is a close association of
inhalational S. aureus pneumonias and
outbreaks of influenza in the
community, and since the mortality of
S. aureus pneumonia is 30%-50%, a
positive sputum culture for S. aureus
in a patient with influenza should be
taken quite seriously.

S. aureus inhalation pneumonia also
occurs in hospitalized patients who are
prone to aspiration and those who
acquire the organism during intubation.
In these cases, there is no classic
pattern on the radiograph since there
can be local consolidation, patchy
infiltrates, or lung abscesses. Patients
with cystic fibrosis have frequent
episodes of pulmonary compromise
that can be attributed to S. aureus and
must be treated aggressively with
appropriate antistaphylococcal agents.

S. aureus pneumonias may also be
caused by hematogenous seeding of
the lung parenchyma. The classic
clinical presentation is the S. aureus
pneumonia associated with right-sided
endocarditis in an intravenous drug
user. Similar pneumonias can also be
seen in hospitalized patients with
infected catheters, dialysis devices, or
infected thrombotic material (10).
Hematogenously-spread S. aureus
pneumonias are also a common cause
of pleural empyema.

Staphylococcus aureus osteomyelitis
is also a frequent and difficult problem
to manage, with some hematogenously
spread and others developing because
of a contiguous focus. Bacteremia in
adults rarely leads to osteomyelitis in
long bones, but vertebral osteomyelitis
is more common. In one large survey
in 1980 (23), S. aureus was the infective
agent in 60% of the cases of vertebral
osteomyelitis. Vertebral osteomyelitis
usually presents as a febrile episode
with excruciating back pain; early
bone scan is the preferred diagnostic
test, but needle aspiration for
diagnosis is often necessary.

Another common clinical presentation
is the S. aureus osteomyelitis that
develops from a contiguous focus as the
result of orthopedic surgery or trauma,
or in association with a diabetic foot

ulcer (2,10). In these situations, bone
samples may be needed for diagnosis,
and critical decisions are often made
concerning removal of prostheses.

S. aureus bursitis should also be
mentioned since 90% of cases of
infective bursitis are caused by this
organism (10). The olecranon and the
prepatellar bursae are the most common
sites, and the overlying skin is hot,
red, and edematous, but the underlying
joint moves freely. Treatment includes
antistaphylococcal antibiotics as well
as repeated aspirations of the infected
bursae (10).

Another type that deserves attention
is staphylococcal food poisoning. This
disease involves person-to-person
transmission; usually a food handler
w'ho is a carrier of a pathogenic strain
of S. aureus contaminates food which
is subsequently improperly stored. The
staphylococci subsequently multiply in
the food substance and produce the
heat stable enterotoxin B which is
ingested. This enterotoxin causes acute
salivation followed by nausea and
vomiting, and then abdominal cramps
and diarrhea. The symptoms appear two
to six hours after ingestion of the toxin-
laden food (depending on the amount
of toxin ingested) and symptoms are
usually limited to 24 hours (1,10).

Methicillin resistant S. aureus (MRSA)
is a special problem. The precise
mechanism of resistance to methicillin
and other B-lactam antibiotics is
unknown, but the presence on the
membrane of a novel, penicillin-binding
protein that is insensitive to B-lactam
antibiotics is at least partly responsible.

There is a wide body of literature
describing the problems and possible
mechanisms of control of MRSA in our
hospitals (24,25). Due to the virulence
of this organism, its increasing
prevalence not only in hospital settings
but now in community settings (24),
and the lack of effective antibiotics
other than vancomycin (Vancocin)®,
it behooves us all as clinicians to
participate fully in the control measures
instituted by our hospitals.

Although laboratories may report
some susceptibility of these organisms
to the cephalosporin or tetracycline
class of antibiotics, the clinician should
not be fooled into using these
antibiotics when methicillin resistance
is reported from the laboratory.

References

1 . Sheagren JN. Staphylococcus aureus: the
persistent pathogen. N Engl J Med 1984;
310:1368-73.

2. Keusch GT, Weinstein L. editors.
Staphylococcal disease. Symposium
prepared by the Upjohn Company 1975.
Kalamazoo, Michigan.

3. Mitchell NJ, Gamble DR. Clothing design for
operating room personnel. Lancet 1974;
1133-6.

4. Hanifin JM, Rogge JL. Staphylococcal
infections in patients with atopic dermatitis.
Arch Dermatol 1977;113:1383-6.

5. Tuazon CU, Perez A, Kishaba T, Sheagren JN.
Staphylococcus aureus among insulin-
injecting diabetic patients: an increased
carrier rate. JAMA 1975;231:1272.

6. Tuazon CU, Sheagren JN. Increased
staphylococcal carrier rate among narcotic
addicts. J Infect Dis 1974;129:725-7.

7. Kirmani N, Tuazon CU, Ailing D. Carriage
rate of Staphylococcus aureus among
patients receiving allergy injections. Ann
Allergy 1980;45:235-7.

8. Raad II, Bodey GP. Infectious complications
of indwelling vascular catheters. Clin Inf Dis
1992;15:197-210.

9. Kaplan MH, Tenenbaum MJ. Staphylococcus
aureus: cellular biology and clinical
application. AmJ Med 1982;72:248-58.

10. Waldvogel FA. Staphylococcus aureus
(including toxic shock syndrome). In:
Mandell, Douglas, Bennett, editors.
Principles and practice of infectious
diseases. New York: Churchill Livingston.
1990:1489-1510.

11. Verhoef J, Verbrugh HA. Host determinants
in staphylococcal disease. Ann Rev Med
1981;32:107-22.

12. Cunningham FG. Other disorders of the
puerperium. In: Cumingham, MacDonald,
Gant, Levino, Giltrap, editors. Williams
Obstetrics. Norwalk (Conn): Appleton and
Lange, 1993:643-50.

13. Strausbaugh LJ. Toxic shock syndrome. Are
you recognizing its changing presentations?
Post Grad Med 1993;94:107-18.

14. Banerjee SN, et al. Secular trends in
nosocomial primary bloodstream infections
in the United States, 1980-1989. Am J Med
1991;91:86S-89S.

15. Nolan CM, Beaty HN. Staphylococcus
aureus bacteremia: Current clinical patterns.
Am J Med 1976;60:495-500.

16. Bayer AS, Lam K, et al. Staphylococcus
aureus bacteremia. Clinical, serologic, and
echocardiographic findings in patients with
and without endocarditis. Arch Intern Med
1987;147:457-62.

17. Sheth NK, Franson TR, Rose HD, et al.
Colonization of bacteria on polyvinylchloride
and Teflon intravascular catheters in
hospitalized patients. J Clin Microbiol 1983;
18:1061-3.

18. Dugdale DC, Ramsey PG. Staphylococcus
aureus bacteremia in patients with Hickman
catheters. AmJ Med 1990;89:137-41.

19. Enhi WF, Reller B. Short-course therapy for
catheter-associated Staphylococcus aureus
bacteremia. Arch Intern Med 1989;149:533-6.

20. Jemigan JA, Farr BM. Short-course therapy
of catheter-related Staphylococcus aureus
bacteremia: a meta-analysis. Ann Intern
Med 1993;119:304-11.

21. King PD. Infectious complications of liver
disease. J Gen Intern Med 1993;8:327-32.

22. Bemardini J, Holley JL, Johnston JR,
Perlmutter JA, Piraino B. An analysis of ten-
year trends in infections in adults on
continuous ambulatory peritoneal dialysis
(CAPD). Clinical Neph 1991;36:29-34.

23. Waldvogel FA, Vasey H. Osteomyelitis: the
past decade. N Eng J Med 1980;303:360-4.

24. Brumfitt W, Hamilton-Miller J. Methicillin-
resistant Staphylococcus aureus. N Eng J
Med 1989;320:118-119.

25. Haley RW. Methicillin-resistant Staphylococcus
aureus: do we just have to live with it? Ann
Intern Med 1991;114:162-4.

JUNE 1994, VOL. 90 241

By now I’m sure that most of you
have become thoroughly frustrated
with the health care debate. Not only
are you bombarded with the media’s
coverage of it, but it is probably
affecting you and your patients
personally.

As physicians, it is very frustrating
and frightening to imagine how our
practices may change. Just as we must
daily face these uncertainties, so must
our patients. They too, are scared and
unsure of what may be happening to
their health care system.

Will I still be able to choose my
own physician?

Will I still be able to select my own
type of insurance coverage?

What kind of benefits will I have if
health care reform passes?

These are just a few of the
questions I am constantly asked by
my patients, and it is up to all of us to
make sure we will have answers that
will be acceptable to both ourselves
and our patients. How can we
accomplish this?

Making a difference

In the next several months, we will
have some excellent opportunities to
become more involved in the debate
over health care reform and influence
the policies of both the WVSMA and
the AMA. Several of us have recently
returned from representing the
WVSMA at the AMA’s Annual Meeting,
where we were involved in many
discussions concerning health care
reform and the AMA’s policies. I
would encourage you to again read
the Patient Protection Act that was
recently sent to you by the AMA. This
is a very powerful program that will
protect patients and will continue to
allow physicians to have a voice in
health care delivery. It has been
accepted quite well by many members
of Congress and will ensure that the
AMA remains involved in the health
care debate.

On the state level, we have been
very successful in the recent primary
election and are beginning to plan
endorsements for this fall. You can be
involved in WESPAC through the $365
Club or other contribution levels, and

you should also participate in your
upcoming general election in some
manner. Regardless of how you
choose to become involved, there is
no question that you need to make
political activity and political action
part of your life as a physician.

Another reality of practicing
medicine in today’s world, is your
involvement with your local
component medical society and the
WVSMA. We are less than two months
away from the WVMSA’s Annual
Meeting, a critical event for all members
because the Council and the House of
Delegates will both convene and you
will have an opportunity to mold the
WVSMA’s policies. I encourage you to
submit resolutions and the make sure
that your county is represented with
members at both the Council and the
House of Delegates meetings.

The WVSMA is only as strong as its
individual component societies, and it
is only as strong as the commitment
of our members on a grass roots
basis.

James L. Comerci, M.D.

242 THE WEST VIRGINIA MEDICAL JOURNAL

Editorial

WESPAC — Now more than ever

The primary election in West Virginia
has come and gone. Sixty-six of the 85
candidates WESPAC endorsed won in
their races. Not only was it significant
that so many of our endorsed candidates
were successful, but also that for the
first time in a number of years, we
were able to contribute significant
sums of money to their campaigns,
nearly $30 thousand.

Of additional importance is the fact
that we should have a similar amount
to spend in the general election in
November. We have these financial
resources thanks to some arm-twisting
by a few members and WVSMA
President Dr. Jim Comerci’s innovative
program of “A Dollar A Day. ” In
response to this challenge, many
members have increased their
contributions from the minimum of
$50 to $365.

Regrettably, a few officers of the
WVSMA and about a third of the
Council members have yet to make a
contribution. Shouldn't every WVSMA
leader and member belong to the
$365 Club? I certainly think so!

Growing up in southern West
Virginia acquaints one early with the
realities of politics in our state. The
saying, “Vote early and vote often, ”
was not merely an attempt at political
humor, but a mentality that still
persists today.

Our profession is currently being
assailed on every side by the president

of the United States, our junior senator,
PEIA, Medicaid, insurers, various
politicians, activist groups, and even
by our own patients who are
demanding more and better care at
lower costs. We have no choice but to
try to defend our right to practice
medicine in a reasonable fashion by-
preserving our right to continue the
traditional physician/patient relationship,
and by preserving our right to set our
own fees and earn a fair wage for our
services.

To achieve these goals, we must
first begin by educating our patients to
the realities of the costs of medicine
and technology, not only by talking to
them on a personal basis, but by
providing them with copies of articles
such as “Your Risk Under Clinton’s
Health Plan, ” which appeared in
Reader’s Digest i his February, and
“Here's Health-Care Reform That
Works, ’’which was published by
Reader's Digest in October 1993.
Another important item which your
patients should read is the full page
ad by neurosurgeon Dr. Gonzalo
Sanchez, which w-as published in the
February 12 issue of the South Dakota
Argus Leader. (Call me at 842-3446
and I’ll send you a copy.)

In addition to better educating our
patients, we must see that the members
of our Legislature are people who are
informed about the realities of medical
care today and the realities of the

proposed health care plans.
Unfortunately, the only way we can
do this is by political action, i.e. by
seeing that people who favor our
positions are elected, and that those
w-ho are obviously opposed to the
private practice of medicine are not
elected.

We have very few avenues to that
end, therefore, I encourage you to give
individual contributions to those
candidates who are friendly to our
cause or who are opposing candidates
hostile to it. By making individual
contributions, as well as $365
contributions each year to WESPAC,
we will enable our officers and
lobbyists to be heard when they
approach members of the Legislature
about medical matters.

With the threat of an unacceptable
form of health care reform rapidly
approaching, this may be our last
chance to make a difference. Time is
running out — so join WESPAC today!!!

Douglas E. McKinney, M.D

JUNE 1994, VOL. 90 243

Intercepted Mail

April 28, 1994

Ms. Sonia Daugherty, Special Assistant
Public Employees’ Insurance Agency
State Capitol Complex
Building 5, Room 1001
1900 Kanawha Boulevard, East

Dear Ms. Daugherty:

This letter is to more formally record my protest to the PEIA, Workers’ Compensation, and
Office of Medical Services of WVHHR’s decision to reimburse non-physician providers at parity
with physicians as indicated on page 3 of the physicians’ payment policy to accompany RBRVS
fee schedules dated April 22, 1994. I would challenge your statement that there was a balanced
discussion and perspectives offered by physician and non-physician Technical Advisory Panel
members as clearly the physician majority of the panel did not feel that parity was warranted in
the situations discussed.

The main issues involved obstetrical services provided by midwives and psychotherapy
services provided by psychologists or social workers. To reiterate the discussion and the
conclusion of the majority of the panel, non-physician providers do not possess the same level
of training or expertise in performing these procedures as physicians do. I frankly believe that
the administrators involved in these decisions have little appreciation of the time and effort that
goes into becoming a physician. To reimburse individuals who have spent far less time, money,
and effort to achieve their midwife, psychology, or social work status at the same level as a
physician, will clearly have a long-term impact on the recruitment of qualified individuals into
the medical field, particularly in the areas of obstetrics and psychiatry.

The primary factors that the payors cite leading to the decision of parity are bogus. Many
non-physician providers do in fact bill the payors independently and are not in the employment
of physicians. Those who arrange consultive or supervisory time with physicians do so only
because of demands placed by insurance carriers for physician input in the care of the patient.
Frankly, with at least some non-physician providers in the area of mental health, I clearly feel
this policy is a good one that insures a higher quality of care for the patient.

Sincerely,

T.O. Dickey III, M.D.

cc: David Lambert, PEIA

Jimmy Mangus, M.D., Office of Medical Services of WVHHR

Andy Richardson, Workers’ Compensation

James Comerci, M.D., President WVSMA

John Vanin, M.D., President WVPA

Michael Lewis, M.D.

Stephen Ward, M.D.

244 THE WEST VIRGINIA MEDICAL JOURNAL

That’s why Congress
must pass the Patient
Protection Act.

There are things insurance companies don’t
want you to know about their health plans.
That’s why you need the facts. So you can make
informed choices and get quality care in spite
of their efforts to keep you in the dark.

The Patient Protection Act will require
insurance companies to give you all the infor-
mation you need before you join a health plan.
They’ll have to tell you what is and isn’t covered
in their plan. What sort of incentives they give
to limit the care you get. What sort of approval
process you have to go through to get the care
you need. And how many people have dropped
out of their plan because they were dissatisfied
with the care they got.

It will also make sure your doctor has a say in
your plan’s medical policies and make it illegal
for your plan to fire your doctor for giving you
all the care you need. What’s more, it will allow
you to choose your own doctor - instead of
having one chosen for you.

In short, the Patient Protection Act requires
insurance companies to give you a full explana-
tion of how their plan’s limitations affect you.
So you and your family can make an informed,
intelligent decision about the one thing that’s
more important than any other. Your health.

This is the moment of truth. Call your senators
and representative now. Demand that they sup-
port the Patient Protection Act. Because when
you’re dealing with the insurance industry,
what you don’t know really can hurt you.

American Medical Association

Physicians dedicated to the health of America

At Annual Meeting

General Scientific Session to focus on prevention,
treatment of peripheral vascular disease

Four diagnostic specialists will
present lectures on the topic of
"Peripheral Vascular Disease -
Prevention , Medical/Surgical
Management and Rehabilitation ” for
the General Scientific Session, which
will take place on Thursday, August 18
from 8:30 a.m. - noon during the
WVSMA’s Annual Meeting at The
Greenbrier.

Scheduled to join Moderator Dr.

John D. Holloway for this session are
Jeffrey W. Olin, D.O., F.A.C.P.,
associate program director of the
Internal Medicine Residency Program
for the Cleveland Clinic Foundation;
Peter Kim Nelson, M.D., assistant
professor of clinical radiology at New
York University Medical Center; C.
Douglas Phillips, M.D., assistant
professor of the Department of
Radiology, Neurosurgery and
Otolaryngology at the University of
Virginia Health Sciences Center; and
William F. Ruschhaupt III, M.D., a staff
physician in the Department of
Vascular Medicine at the Cleveland
Clinic Foundation.

Information about these four speakers
begins below. A registration form for
this year’s WVSMA Annual Meeting is
printed on page 249, and more details
can be obtained by phoning Nancie
Diwens at (304) 923-0342.

Speakers highlighted

Dr. Olin received his D.O. degree in
1977 from the Kansas City College of
Osteopathic Medicine in Kansas City,
Mo. He interned at Grandview Hospital
in Dayton, Ohio, and completed a
three-year residency at the Cleveland
Clinic Foundation, where he served as
chief medical resident.

From 1981-83, Dr. Olin served as a
fellow in hypertension and nephrology
at the Cleveland Clinic Foundation.
Following his fellowship, Dr. Olin
joined the faculty of the Department
of Medicine, Division of Nephrology
at The Western Pennsylvania Hospital
in Pittsburgh. During his three years at
the hospital, Dr. Olin also served in
other capacities, including director of

Dr. Olin

the Hypertension Clinic, associate
program director of the Internal
Medicine Training Program, and co-
chief of the Subdivision of Nephrology.

Dr. Olin relocated to Cleveland in
1986 to become an associate staff
member in the Department of Vascular
Medicine at the Cleveland Clinic
Foundation. The next year, he was
promoted to head of the Section of
Atherosclerosis and Lipids and was
also named program director of
residency training for the Department
of Vascular Medicine.

In 1992, Dr. Olin accepted his
current post as associate program
director of the internal medicine
residency in the Division of Medicine
at the Cleveland Clinic. In addition, he
is also an associate professor of
medicine at Ohio State University and
a professor of medicine at Penn State
University.

An associate editor of the Journal of
Vascular Medicine and Biology, Dr.
Olin also serves on the editorial board
and is a reviewer for the Cleveland
Clinic Journal of Medicine and several
other medical publications. He is a
diplomate of the American Board of
Internal Medicine and the American
Board of Nephrology, and is a fellow
of the American College of Physicians
and the American College of Cardiology.

Dr. Phillips

Dr. Nelson obtained his medical
degree in 1986 from the Louisiana
State University School of Medicine in
New Orleans, where he received The
Adamo Award in Neuroscience and
the Medical Pharmacology Award. He
interned at Barnes Hospital in St. Louis
and then completed a three-year
residency in radiology and a two-year
fellowship in diagnostic radiology at
the Mallinckrodt Institute of Radiology
in St. Louis. In addition, while working
on his fellowship at Mallinckrodt, Dr.
Nelson also completed a one-year
fellowship in interventional
neuroradiology at New York University
Medical Center.

In 1992, Dr. Nelson assumed his
present position as an assistant
professor of clinical radiology at New
York University Medical Center. He
also serves as an assistant attending in
radiology at both Tisch Hospital and
Bellevue Hospital.

Dr. Nelson has had articles printed
in several medical journals, as well as
written book chapters and abstracts
for a variety of scientific publications.

Dr. Phillips served at the U.S. Air
Force Academy from 1977-78, and
then attended Marshall Liniversity
where he received a Regents B.A.
degree in 1981 and his medical degree
in 1984. He completed his postgraduate

246 THE WEST VIRGINIA MEDICAL JOURNAL

training at the University of Virginia
Medical Center as a resident in
diagnostic radiology from 1984-87; as
academic chief resident from 1987-88;
as a fellow in neuroradiology from
1988-89; and as an instructor in
neuroradiology from 1989-90.

Before he accepted his current role
as an assistant professor of radiology,
neurosurgery, and otolaryngology -
head and neck surgery at the
University of Virginia Health Sciences
Center, Dr. Phillips held locum tenens
positions at four hospitals in Virginia.

A diplomate of the National Board
of Medical Examiners, Dr. Phillips is
certified in diagnostic radiology by the
American Board of Radiology, and is a
senior member of the American
Society of Neuroradiology.

Very active on committees at the
University of Virginia, Dr. Phillips has
served as a visiting professor at

Eastern Virginia Medical School and
has lectured extensively at medical
meetings in Virginia and throughout
the United States.

Dr. Ruschhaupt is a native of
Pittsburgh who obtained his medical
degree from the University of
Pittsburgh in 1972. He completed an
internship in internal medicine at
Dallas Veterans Administration
Hospital at the University of Texas
Southwestern, and then did a two-year
residency in internal medicine at the
Cleveland Clinic Foundation.

After his residency, Dr. Ruschhaupt
joined the U.S. Army and served as
chief of Emergency Medical Services
and chief of the Peripheral Vascular
Disease Clinic at Tripler Army Medical
Center from 1975-78. After his anny
duty, Dr. Ruschhaupt accepted his
current position as a staff physician at
the Cleveland Clinic Foundation. In

1985, Dr. Ruschhaupt received an
M.B.A. degree from Case Western
Reserve University in Cleveland, and
during his years at the Cleveland
Clinic Foundation he has also held
positions as program director of
Patient Care Systems and project
director of the Patient Financial
Services’ Systems Implementation
Project.

A diplomate of the American Board
of Internal Medicine, Dr. Ruschhaupt
is also a member of the American
College of Physicians, the American
Heart Association, the American
Society of Internal Medicine, and the
Society of Vascular Medicine and
Biology. A trustee of Ronald
McDonald Children’s Charities and
Children’s Oncology Services of
Northern Ohio, Dr. Ruschhaupt is also
president of the Ohio Society of
Internal Medicine.

Special evening of dancing, comedy
planned for Annual Meeting

The musical group “Good Time
Jazz’’ will kickoff a lively evening of
free entertainment at 9 p.m. on
Friday, August 19 during the
WVSMA’s Annual Meeting at The
Greenbrier. In addition to the dance
music, humorist Pat Leimbach will
also entertain guests with her “Wit of
the Country. ”

“Good Time Jazz” is a band which
plays a variety of music including
Ragtime and Dixieland, Swing and
the Big Band Era, as well as the
standards of the 50s through the 90s.
This band is under the direction of
Dr. George West from Harrisonburg,
Va., and features many musicians
who are also members of Hal Walls
Orchestra, wrhich regularly performs
at The Greenbrier.

Leimbach is a farm wife from
Vermilion, Ohio, who is a partner
with her son in a potato, vegetable
and grain operation. She writes a
newspaper column called “ Country
Wife” which appears in a number of
farm publications around the nation.
Leimbach is also the author of three
books, “A Thread of Blue Denim. ”
“All My Meadows , ” and “ Harvest of
Bittersweet. ”

The Wall Street Journal in a front
page feature referred to Leimbach as
"the Erma Bombeck of the Farm
Belt.” She subsequently appeared on
“ Good Morning America ” with

Leimbach

Bombeck. Leimbach has also been a
guest on the “ Today Show, ” “ Larry
King Live, ” and PBS-TV’s " Market to
Market. ” She has entertained
audiences in 45 states and four
Canadian provinces with her “Old
Farm Wives Tales. ”

A graduate of Case Western
Reserve University, Leimbach did
graduate study at McGill University in
Montreal. She was a modern
language teacher in her home county
for several years and is a member of
the Associated Country Women of
the World, the Ohio Agricultural
Council, Women for Ohio Agriculture,
and the American Agri-Women. She
was appointed by Secretary of
Agriculture Bergland to the Project
for Women of the USDA.

WVSMA endorses new
OSH A training kit
by Current Concepts

Current Concept Seminars, Inc.,
has developed “The Complete
OSH A Training Kit, ” a videotaped
lecture presentation with trainer’s
text designed to simplify the task
of employee training under the
OSHA Bloodborne Pathogens
Standards and the OSHA Hazard
Communication Standards. This
training kit has been endorsed by
the WVSMA and is available to
members for $79.

Last year over 25 national and
state professional associations
endorsed Current Concepts’
compliance manual entitled
“ Infection Control in Healthcare, ”
in order to help notify their
members of the Bloodborne
Pathogens Standards.

To order this new training kit,
phone Current Concepts at
(904) 620-8905. Please specify
when you place your order, that
you are a member of the WVSMA.

JUNE 1994, VOL. 90 247

Special honor

W. Warren Point III, M.D., of Charleston,
proudly holds the William J. Maier Jr.
Education Award for 1993-94, which he
received for the outstanding contributions
he has made to education in the health
sciences. This annual award is sponsored
by the Robert C. Byrd Health Sciences
Center of WVU and CAMC, and is funded by
the Sarah and Pauline Maier Foundation, Inc.

Research Day winners

The Individuals who received honors at the annual Research Day competition sponsored by
the Charleston Division of the Robert C. Byrd Health Sciences Center of WVU and CAMC
were (from left to right) Bryan K. Richmond, M.D.; John V. Onestinghel HI, M.D.; Lora L.
Thaxton, MSHI; R. Todd DePond, M.D.; Heather L. Mertz, MSHI; Jerry E. Owensby, M.D.; and
Kent L. Carter, Pharm.D. Drs. Richmond and Onestinghel were the first and second place
winners, and Thaxton was the third-place winner in the category for review/subject
presentations. Mertz received the first place prize in the original research category; Drs.
Owensby and DePond, tied for second place; and Dr. Carter was presented the prize for
third-place.

WPBY-TV sponsoring “Women’s Health Initiative”

As part of their outreach project, the “Women's Health Initiative, ’’WPBY-TV is broadcasting a series
of programs designed to inform viewers of the health problems affecting women in West Virginia.

The first shows of this series began airing in May and the remaining schedule of programs is as follows:

June 27 - 10:30 p.m.

“America’s Women: In Pursuit of
Health”

June 29 - 10:30 p.m.

“Health Chronicles - In Search of a
Miracle”

July 3 - 7 p.m.

“A Women’s Heart”

July 28 - 8:30 p.m.

“In the Public Interest - Heart Disease”

August 16 - 9 p.m.

“The Famine Within"

August 16 - 10:30 p.m.

“The Famine Within: What is Perfect?”

August 25 - 8:30 p.m.

“In the Public Interest - Smoking”
September 1-10 p.m.

“Straight Talk on Menopause ‘Signs
and Symptoms’”

September 8 - 10 p.m.

“Straight Talk on Menopause ‘Taking
Charge’

September 22 - 8:30 p.m.

“In the Public Interest - Depression”

October 6 - 8:30 p.m.

“In the Public Interest - Breast Cancer”

October 24 - 9 p.m.

“A Woman's Health

October 27 - 8:30 p.m.

“In the Public Interest - Domestic
Violence”

Also airing in October

(dates and times to be announced)

“Breast Cancer . . . Speaking Out”

“Breast Cancer . . . Speaking Out . . .
Again”

In conjunction with the Women ’s Health Initiative , brochures have been published entitled "Six Health Issues of Concern
to Every Woman. "These brochures are available at district Department of Human Services centers, libraries, women’s
centers, county health departments, clinics, and doctor’s offices. The printing of these brochures was funded by the WVSMA
and WVSMAA, and the WPBY-TV Women’s Health Initiative Programs have been underwritten by Cabell Huntington
Hospital’s Women’s Health Services. In addition, three WVSMAA members, Jean Skaggs, Bonnie Fidler and Linda Turner are
serving on the Women’s Health Initiative Advisory Task Force.

For details about the Women ’s Health Initiative and Community Outreach, contact Robin Pyle at WPBY-TV, 696-6630.

248 THE WEST VIRGINIA MEDICAL JOURNAL

The West Virginia State Medical Association’ s

August 17-20, 1994

The Greenbrier

White Sulphur Springs, West Virginia

/ .

T Sign Up NOW!

Please be sure to make hotel reservations in advance by calling 1-800-624-6070. The Greenbrier
will fill up quickly because the State Fair will be going on during the same week.

1994 Annual Meeting

Name

Conference Cost:

WVSMA member

$125

Address

Additional:

non-member

$175

City State Zip Code

Thursday, Aug. 18

Specialty

Learn and Learn
(CME Credit)

member/ non-member
spouse/ student

$40
$ 25

Phone

Friday, Aug. 19
Lunch and Learn
(CME Credit)

Payment by: Check _ Visa MasterCard

member/non-member
spouse/ student

$40
$ 25

TOTAL:

Card Number.

Expiration Date
Signature

If paying by check, please send registration form and check to:
West Virginia State Medical Association
P.O. Box 4106, Charleston, WV 25364

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Raleigh County Medical Society -
Beckley

June 30

“A Current Look at Prostate Cancer,”
Jim Simon, M.D., 6:30 p.m., Black
Knight County Club

West Virginia State Medical
Association - Charleston

June 25

“Marbury v. Madison,” Holiday Inn,
Clarksburg

June 28

“1994 Medical Billing Seminar.” Days
Inn, Flatwoods

August 13

“Level One Loss Prevention,” Beckley
Hotel, Beckley

August 17-20

“WVSMA’s 127th Annual Meeting,”
The Greenbrier, White Sulphur
Springs

August 27

“Marbury vs. Madison,” Radisson
Hotel, Huntington

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Logan □ Logan General Hospital, July 15,
11:45 a.m., “Trauma Resuscitation:
Optimizing in the Golden Hour,”
CAMC Trauma Services

Madison □ Boone Memorial Hospital,
July 12, 6:30 p.m., “Chest Trauma,”
Frank C. Lucente, M.D.

Man □ Man Appalachian Regional
Hospital, July 20, 6:30 p.m., “Medical
Evaluation of the Sexually-Abused
Child,” Kathleen Previll, M.D.

Oak Hill □ Plateau Medical Center,
June 28, 6:30 p.m., “Pediatric
Trauma,” A. Margarita Torres, M.D.

□ Plateau Medical Center, July 26,
6:30 p.m., “Lumbar,” Constantino Y.
Arnores, M.D.

Point Pleasant □ Pleasant Valley
Hospital, July 28, noon, “Medical
Oncology Emergencies,” Steven
Jubelirer, M.D.

Until there's a cure,
there's the
American Diabetes
Association.

Prasadarao B. Mukkamala, MD

Union Square • 1 Monongalia Street • Charleston, WV 25302

Dr. Mukkamala is a Diplomate of the American Board of Physical Medicine and Rehabilitation
and the American Board of Electro-Diagnostic Medicine.

Specialist in Electromyography and Nerve Conduction Studies

V J

For appointment, call: (304) 344-5153

250 THE WEST VIRGINIA MEDICAL JOURNAL

July

7- 8-Second International Conference on the
Varicella-Zoster Virus (sponsored by the
VZV Research Foundation), Paris

8- 9-Using Data to Improve Quality in
Healthcare (sponsored by the National
Association for Healthcare Quality), Houston
11-13-American In Vitro Allergy/
Immunology Society, Cambridge, Mass.
17-18-2nd Annual Alumni Symposium
Featuring the William H. Saunders
Lectureship (sponsored by Ohio State
University), Galloway, Ohio

August

5-6-Quality Improvement in Healthcare: An
Introduction (sponsored by the National
Association for Healthcare Quality), Chicago

5- 7— 2nd Annual Conference of Civil War
Medicine (sponsored by the National
Museum of Civil War Medicine), Frederick,
Md.

8-10-American Hospital Association, Dallas
14-17-Midwest Surgical Association,
MacKinac Island, Mich.

17-20— WVSMA's 127th Annual Meeting,
White Sulphur Springs
19-20-Healthcare Quality Management:
Review and Study Session (sponsored by
the National Association for Healthcare
Quality), Boston

19-20-Communication Approaches for
Tracheostomized and Ventilator Dependent
Patients (sponsored by Voicing!, Inc.)

Chapel Hill, N.C.

25- 27— Southern Association for Oncology,
Sea Island, Ga.

26- 27-Case Management and Utilization
Management in a Changing Healthcare
Environment (sponsored by the National
Association for Healthcare Quality),
Pittsburgh

September

6- 11— 18th Annual Meeting of the American
Academy of Neurological and Orthopaedic
Surgeons, Las Vegas

8-10-American Gynecological and
Obstetrical Society, Hot Springs, Va.

10- 13-Seventh Annual Update in Internal
Medicine (sponsored by Ohio State
University), Columbus

11- 14-American College of Emergency
Physicians, Orlando, Fla.
16-17-Communication Approaches for
Tracheostomized and Ventilator Dependent
Patients (sponsored by Voicing!, Inc.),
Louisville, Ky.

For More Information . . .

Contact the Journal at (304) 925-0342.

Poetry Corner y

Clouds and Dreams

As a child I watched the clouds drift by
In a lazy azure summer sky
Flat on my back in soft green grass
I dreamed of the future and not the past

The day was warm and I remember it well
I can still hear the birds sing, and smell
The scent of rose and purple lavender
As the clouds formed valleys and little hills

I kicked my shoes off a nd worn socks too
Heard a distant dog 's bark and a kitten 's mew
Rubbed my toes in the warm moist earth
Watched the clouds coalesce, then disperse

A soft slumber slowly took its place
As the sun danced with shadows across my face
I dreamed of a pond and an old wooden boat
Drifting and rocking for hours afloat

Now the future is here and much older am I
And worn and drained I long for that sky
To capture those clouds, earth, grass and joy
And the innocent slumber I had as a boy.

Phillip V. Swearingen, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward, M.D.,
Editor, West Virginia Medical Journal, P. O. Box 4106, Charleston, WV 25364.

JUNE 1994, VOL. 90 251

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

Three-year study to
look at Lyme disease
in West Virginia

Physicians in the state are urged to
assist the Bureau of Public Health in a
three-year study of Lyme disease and
Lyme disease-like illnesses in West
Virginia, in order to learn more about
the etiology and ecology of this
disease.

This study is being conducted by
staff with the Bureau’s Division of
Surveillance and Disease Control in
cooperation with WVU's Department of
Microbiology/Immunology, the West
Virginia Division of Natural Resources
and local health departments. It is
being funded by the U.S. Centers for
Disease Control and Prevention.

Lyme disease is a bacterial infection
linked to bites from deer ticks. In
1993, an unusually high number of
Lyme disease cases were diagnosed in
Greenbrier and Raleigh counties. Yet
neither the state nor this region of it
have been known to have high deer
tick populations. The study will try to
determine if more deer ticks exist in
West Virginia than previously
thought, or if other tick species may
carry the bacteria linked to Lyme. It
will also find out if ticks transmit
other bacteria which may cause
illnesses with similar symptoms.

To accomplish these results, ticks
found on humans and small animals
will be collected to determine their
species and what organisms they may
be carrying that could cause Lyme or
its symptoms. In addition, people
who have been diagnosed with or are
suspected of having Lyme disease will
be needed to take part in the study.

One of the first symptoms of Lyme
is a red, bull’s eye-type rash, and
other early symptoms may include
muscle and joint aches, headaches,
stiff neck, fatigue, fever, meningitis,
and joint pain and swelling. People
with these symptoms and those who
know they have recently been bitten

by a tick should immediately visit a
doctor. If they wish to take part in the
the study, these individuals will be
asked to undergo a series of blood
tests, a biopsy and other procedures.

To get a true picture of Lyme in
West Virginia, it is imperative for
physicians to accurately diagnosis and
report this disease. If physicians
suspect Lyme diseasse, they should
contact their local health department
for the Lyme disease study protocol
and specimen containers.

For more information, call State
Epidemiologist Loretta Haddy at
(304) 538-5338 or 1-800-423-1271.

Communities begin
program to increase
AIDS/ HIV awareness

The statewide fight against AIDS and
HIV, the vims that causes AiDS,
entered a new phase last month when
the Bureau of Public Health’s AIDS
Program sponsored a live, interactive
teleconference called “ HIV Prevention
Community Planning .”

Health officials used the broadcast
to set in motion a new plan, the
community action group or CAG, to
coordinate state AIDS strategies with
prevention efforts at the local and
regional levels. Under this new plan,
the state will be divided into eight
multi-county regions, each of which
will be represented by a CAG. The
members of these CAGs will, in turn,
elect representatives to a centralized
planning group, the West Virginia
AIDS Task Force.

Staff are looking for a broad
spectrum of people to help organize
the regional community action
groups, including health care
professionals, elected officials, clergy,
members of minority groups, lesbians
and gay men, parents, and business
people, as well as persons who have
AIDS or live with someone who has
the disease.

For more details about this new plan
of action for fighting AIDS and HIV in
West Virginia, call the West Virginia
AIDS program at (304) 558-2950 or
1-800-642-8244.

WIC celebrates 20
years of service

The West Virginia Women, Infants
and Children’s Special Supplemental
Food Program is celebrating a 20-year
track record of providing an effective,
cost-efficient wellness program to
some of the state’s most vulnerable
children.

Also known as WTC, this program
was first established in West Virginia
in May of 1974, and that first year, it
served 1,968 participants. In 1994, it's
projected that more than 51,000 West
Virginians will receive WIC benefits.

The WIC Program educates mothers
and mothers-to-be about nutrition
and provides drafts for foods rich in
calcium, iron, protein and vitamins A
and C, in order to improve their
health and the health of their children
under the age of five.

Studies show that for every dollar
spent on a pregnant woman in the
WIC program, a total of $3.13 is saved
on Medicaid costs in the first 60 days
of an infant’s life. WIC has also been
credited with reducing childhood
anemia, low birth-weights, infant
mortality and premature births.

To qualify for WIC, a woman,
infant or child must first be shown to
have a nutritional risk, such as anemia
or inadequate diet. The program
serves nutritionally-deficient women
and children whose family income
falls within the 185% of the poverty
level defined by the government.

For more information about the
West Virginia WIC Program, call
Denise Ferris at (304) 558-0030.

252 THE WEST VIRGINIA MEDICAL JOURNAL

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That's Turnkey Business Systems, an award-winning
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Free Inpatient Treatment Program

For Schizophrenia or Schizoaffective Disorders

Highland Hospital is offering a free treatment program for acute exacerbation of
chronic schizophrenia or schizoaffective disorder using an investigational medication.

If the treatment is effective, the candidate may continue outpatient treatment with
the medication for one year at no cost. There is no charge for the inpatient or
outpatient programs.

For more information,

Contact: Charles C. Weise, M.D., (304) 925-2159.

I miurr\f'VT\f f\i* a am at

Robert c. Byrd
health Sciences center

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Professorship created
to honor Dr. Lapp

To honor one of its
most accomplished
faculty members, the
WVU School of
Medicine created The
N. Leroy Lapp, M.D.,
Professorship in
Pulmonary and
Critical Care Medicine
on May 6.

Dr. Lapp joined the
WVU faculty in 1966,
while on the faculty of the Appalachian
Laboratory for Occupational Respiratory
Diseases in Morgantown. He became a
full-time WVU faculty member in 1975,
and is a professor in the Section of
Pulmonary and Critical Care Medicine in
the Department of Medicine.

“Dr. Lapp has worked for nearly 30
years to improve the health of West
Virginians, and people around the
world,” said Dr. Robert M. D’Alessandri,
dean of medicine and vice president for
health sciences. “His work in pulmonary
diseases -- especially in research into
effects of occupational exposures to lung
irritants like coal dust -- has made it
possible for WVU to remain a leading
institution in the investigation and
treatment of lung disease.”

“The Best Doctors in
America” book lists 10
WVU faculty members

Ten WVU physicians were selected
by their peers to be included in the
recently published book, "The Best
Doctors in America."

The WVU physicians who were
listed in the book were included
because their peers filled in their
names most often on a survey which
asked, “If a friend or loved one came
to you with a medical problem in your

field of expertise and for some reason
you could not handle the case, to
whom would you send them?”

The physicians featured in the book
include: Dr. Lenore Breen, associate
professor of neuro-ophthalmology;

Dr. Bharati Desai, director of the
child/adolescent program in the
Department of Behavioral Medicine
and Psychiatry; Dr. Robert A.
Gustafson, associate professor of
pediatric cardiothoracic surgery; Dr.
Ludwig Gutmann, professor and chair
of the Neurology Department; Dr.
Ronald C. Hill, associate professor of
cardiothoracic surgery; Dr. Donald L.
Lamm, professor and chair of the
Department of Urology; Dr. John V.
Linberg, professor of ophthalmology;
Dr. Gordon F. Murray, professor and
chair of Department of Surgery; Dr.
Michael I. Sorkin, associate professor
and section chief of nephrology; and
Dr. Dianne W. Trumbull, assistant
professor of behavioral medicine and
psychiatry.

Charlton named
distinguished teacher

Dr. Judie F.
Charlton, assistant
professor of
ophthalmology,
has been chosen
to receive the
1994 Distinguished
Teacher Excellence
Award in the
WVU School of
Charlton Medicine.

Dr. Charlton was
selected for this honor because of her
devotion to improving teaching and
her development of the curriculum
for a four-year ophthalmology
residency. Eight medical school
professors were nominated for this
award by students and faculty.

During her career at WVU, Dr.
Charlton has also been been cited for
creating a special training program for
ophthalmic assistants and for her
involvement in community health. She
is a member of the Ophthalmology
Residency Review Committee and an
examiner for the American Board of
Ophthalmology.

Prescott lectures,
accepts editorial post

Dr. John Prescott,
associate professor/
medical director and
chair of emergency
medicine attended
the recent Joint
Service Symposium
entitled “ Emergency
Medicine on the
Riverwalk ,” in San
Antonio, Texas.

Dr. Prescott was one of the several panel
members who discussed “ E.D .
Management Leading to the Future."

In addition, Dr. Prescott was also
named associate editor of “ Emergency
Medicine ,” a comprehensive textbook
to be published by W. B. Saunders
next spring. Several chapters to this
textbook will be contributed by WVU
emergency medicine faculty members.

Junior high teachers
to receive training

The HSC's Office for Social Justice has
been awarded a $25,000 grant under the
Dwight Eisenhower Math and Science
Act to establish a Pre-college Health
Science and Technology Academy.

The academy will bring 10 eighth
grade teachers from Kanawha and
McDowell Counties to WVU this
summer for training workshops. The
workshops will focus on creating
hands-on projects in math and sci-
ence. In addition, the teachers will be
trained in multicultural and diversity
sensitivity, self-esteem building,
leadership and motivation.

Obituary

Daniel T. Watts, Ph.D., 77,
founding chair of the Department
of Pharmacology in the School of
Medicine, died May 11 in Richmond.

Dr. Watts was on the faculty
from 1953-66. At the time of his
death, he was the retired dean of
the Medical College of Virginia's
School of Basic Sciences.

Prescott

254 THE WEST VIRGINIA MEDICAL JOURNAL

FERRELL

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Specializing in public
relations and advertising
for the health care industry

1116 Smith Street
Suite 217

Charleston, WV 25301
(304) 340-4254

MARK YOUR CALENDAR

Charleston Area Medical Center
Presents

Advanced Trauma Life Support Course (ATLS)

Saturday-Sunday, August 20-21, 1994
V J

Program Director:

C. Frank Lucente, M.D.

Director of Trauma Critical Care
Charleston Area Medical Center

Location:

Charleston Area Medical Center
Education & Training Center
Charleston, West Virginia

For More Information:

For additional information, please contact the CAMC - Continuing Education
and Conference Services Department - 348-9581.

Registration is Limited.

Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

Inco, MU medical cost
containment program
extremely successful

An innovative health care cost
containment program developed by
Inco Alloys International and the
Marshall University School of Medicine
is working so well an Inco executive is
recommending it to others — including
Governor Gaston Caperton.

M. E. Cunningham, director of
administration for Huntington's Inco
plant, said that before “INCOnet
Advantage” began a year ago, the
company’s medical costs were growing
four times as fast as inflation. In fact,
costs nearly doubled between 1985
and 1992, even though employment
dropped.

Unwilling to wait for the government
to reform health care, Inco officials
approached Dr. Robert Walker of the
Marshall School of Medicine about
developing a cooperative program.

After months of intense work by
representatives of Inco, its employees,
and Marshall’s Department of Family
and Community Health, INCOnet was
bom in April 1993-

Cunningham has been so pleased
with the program that he recently
wrote a letter to Governor Caperton in
which he stated, “We are delighted to
recommend this program to people in
the business community and would
recommend that the state seriously
consider the INCOnet Advantage
Program as a model for adoption by
the PEI A.”

With INCOnet, insurance rates
actually declined this year for COBRA
transitional coverage available to
fomier workers, Cunningham said. The
1 percent decline reversed a three-year
upward spiral in which rates had
climbed an average of 18 percent a
year. The program provides patient
care and manages health care services
for 1,400 employees at the company’s
plants in I luntington and Bumaugh,
Ky., the workers’ dependents, and
approximately 150 recent retirees.

“The PPO has allowed us to
maintain a high quality of medical
care while establishing cost control
measures that did not formerly exist,”
Cunningham said. “Our experience
indicates that the concept of using a
primary care physician as the
gatekeeper of care, which includes
the responsibility of managing and
tracking specialists and hospital costs,
promises to be even more cost-
effective and efficient in the future.”

According to Walker, INCOnet
actually is considered a modified PPO
because it is so customized that it does
not fit neatly into existing categories of
health care plans. Like a PPO, it offers
employees lower costs if they use
network doctors, who have agreed to
provide care within certain financial
guidelines. Unlike traditional PPOs,
however, INCOnet consists only of
primary care physicians. Employees
are encouraged to choose a personal
or family doctor from a list of about 50
Marshall and private physicians across
the Tri-State. Then, when they need
surgery or subspecialty care, patients
and their doctors can choose any
specialist or facility.

“As the trend continues toward
managed care, we need to recognize
that no one is better qualified to
manage a patient’s care than the
patient and his or her own doctor,”
Walker said. “If the health care team
does need to be expanded, patients
and their doctors call the shots in
putting it together. We believe that
this kind of partnership helps keep
costs under control while actually
improving patient care,” he added.

Rural Datafication
Conference features
paper by MU faculty

Medical practitioners, faculty and
students working in rural areas are
increasingly demanding access to
cutting-edge computerized information
from the field, according to a paper
written by Michael McCarty, coordinator
for rural health education; Jan I. Fox,
chairman of Marshall’s Department of
Academic Computing; and Arnold
Hassen of the West Virginia School of
Osteopathic Medicine.

MARSHAUMlNIVERSITY

The paper, which McCarthy presented
at the Rural Datafication Conference in
Minneapolis last month, stated that “The
challenge faced by West Virginia and
other states is to provide useful, user-
friendly resources in a cost-effective and
timely manner, and these challenges will
continue until and even after the
backroads of the 'information highway’
are paved.”

Educators at West Virginia’s health
professions schools hope that by
providing these technological resources
to rural Learning Resource Centers, they
will enhance health care education,
increase the recruitment and retention
of rural practitioners, and improve
health care delivery to rural areas of the
state,” McCarthy said.

Marshall developed its RuralNet
computer network several years ago
to support medical students doing
nine-month rural rotations in the
school’s Rural Physician Associate
Program. The system later expanded
to serve all students studying health
professions who are taking rural
rotations at Kellogg and Rural Health
Initiative sites.

Today, electronic information from
all West Virginia medical schools is
available at the schools and at 16
Kellogg/RHI Learning Resource
Centers and more than 100 subsites.
Each Learning Research Center has
computers equipped for on-line
communication and has access to the
West Virginia Network for Educational
Telecomputing. RuralNet has become
the LRCs’ primary vehicle for electronic
communications and Internet access,
McCarthy explained.

Marshall’s RuralNet health care
information services also will be
presented in October at meetings of
the American Public Health Association
and the Association of American
Medical Colleges.

256 THE WEST VIRGINIA MEDICAL JOURNAL

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Using specially designed straps and harnesses
to permit her to hold a racket and stay upnght
in her wheelchair, Donna is the only quad player to
compete in an Open Division of Wheelchair Tennis.
She ranks No. 1 in Doubles and No. 7 in Singles.

Donna is also an executive director of a
New York Independent Living Center and a loving
wife. While Donna fights to get on with her life,
she hopes that a cure for MS will someday be
found. The National Multiple Sclerosis Society is
bnnging that day closer by funding vital research
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Alliance

News

We finally did it!

The West Virginia State Medical Association Alliance has talked for years about consolidating the annual
convention from four days to two days, and at long last we have finally done it.

This year, the Pre-Convention Board Meeting will begin at 10 a.m. in the Fillmore and Van Buren Rooms. The
President's Luncheon will follow in the Crystal Room at 12:30 p.m. After this luncheon, the House of Delegates
will convene at 2 p.m. During this session, each county president will be allowed to talk for two minutes. Their
written reports will be in the booklet given out at the convention.

On Friday evening, the entertainment will be great! At 9 p.m., Dr. George West from Harrisonburg, Va., and
his musical group will begin playing a lively variety of dance music. Then at 9:43 p.m., Pat Leimbach from
Vermillion, Ohio, will regale us with stories from her past. Leimbach is a journalist, humorist and author, who
will have copies of her book to autograph. After Pat entertains us with her ancedotes, Dr. West's musical combo
will return so we can continue dancing the night away. The dance and Pat Leimbach's presentation will all be
free of charge for guests attending the WVSMA and WVSMAA Annual Meetings, so please plan on being a part
of this fun-filled evening!

Saturday morning's schedule will begin early with the Past Presidents' Breakfast in the Washington Room at
8 a.m. The House of Delegates will convene again at 9:30 a.m. with the installation of the new officers and
regional directors. Addresses will then be presented by Dr. Robert D'Alessandri, dean of the WVU School of
Medicine; Dr. Charles McKown Jr., dean of the MU School of Medicine; Barbara Tippens, AMAA president; and
Mildred Taylor, SMAA president.

In the afternoon, the Post Convention Meeting/Luncheon will take place in the Crystal Room at 12:30 p.m. At
2:30 p.m., we will all be ready for some recreation, so we have reserved four courts for tennis and the golf
putting area is available. In addition, if anyone wants to hike or play bridge, they are welcome to make their
own arrangments. As a special extra attraction at this year's meeting, Jo Ann's Fashions of Beckley will have an
AMA-ERF Benefit Boutique set up in the Buchanan Room, which is located next to our main meeting room. Be
sure to shop there while you are attending the convention.

Sara Townsend, convention chairman, and Ruth Gilbert, convention co-chairman, have done a tremendous
amount of work planning this year's convention. I am very indebted to them and I want to express my heartfelt
thanks for a job well done.

It's going to be wonderful! Please be there with me for this special two-day convention.

Sincerely,

Carole Scaring

WVSMAA President

258 THE WEST VIRGINIA MEDICAL JOURNAL

New Members

We would like to welcome the
following new members to the WVSMA:

Physicians

Manuel E. Molina, MD
415 Morris Street, Suite 104
Charleston, WV 25301

Naba Goswami, MD
1025 Main Street #518
Wheeling, WV 26003

Wilfrido Tolentino, MD
365 Harper Park Drive
Beckley, WV 25801

Residents

Hussein Abdelhalim, MD
Alexandria, LA

Deniz F. Bastug, MD
Annandale, VA

D. Duane Berry, DO
St. Albans, WV

David A. Deardorff, MD
Morgantown, WV

Joseph Devono III, DO
Charleston, WV

James Duthie, MD
Barboursville, WV

John Fulginiti, MD
Morgantown, WV

James D. Garnett, MD
Morgantown, WV

Norman P. Gebrosky, MD
Morgantown, WV

Joseph M. Hartzog, MD
Morgantown, WV

John P. Henderson II, MD
Morgantown, WV

Sarah I. Hussain, MD
Morgantown, WV

Anas Y. Khouri, MD
Huntington, WV

Kenneth R. Kreisler, MD
Morgantown, WV

Christopher Lambert, MD
Huntington, WV

Patricia K. Mahoney, MD
Morgantown, WV

Suzannah K. McCuen, MD
Morgantown, WV

Anurag Mehta, MD
Morgantown, WV

Sharon R. Metzger Richens, MD
Morgantown, WV

Stacey E. Moore, MD
Charleston, WV
Maurice E. Nida, DO
Charleston, WV
John F. Oliveti, MD
Stow, Ohio

Leela Patel, MD
Charleston, WV

Thiagarajan Ramcharan, MD
Huntington, WV

David A. Ricche, MD
Charleston, WV

Gary F. Roberts, DO
Charleston, WV

Anthony A. Saweikis, MD
Morgantown, WV

James E. Stollings, DO
Dunbar, WV

Timothy L. Thistlethwaite, MD
Charleston, WV

Mohammad Wasay, MD
Huntington, WV

Daniel J. Wood, MD
Charleston, WV

WESPAC Members

We would like to thank the
following physicians and alliance
members for their contributions to
WESPAC:

Physicians

A Dollar A Day Club

(Designates more than $365 in
contributions)

Kanawha

Thomas Dickie
William C Morgan Jr.

Sustainer Members
Logan

Raymond O. Rushden

Tug Valley

Diane Shaffer

Alliance Members
Sustainer Members

Mercer

Alice Edwards

'' X H AnIE ~\0 Bt VERY WAKEFUL \NWE tO X EAT
MOTHER 5UEAK5 CARROTS INTO EVERYT hiws. "

JUNE 1994, VOL. 90 259

Obituaries

Robert K. Fankhauser, M.D.

Dr. Robert K. Fankhauser, 75, of
Hilton Head Island, S.C., died May 1,
in Hilton Head.

A longtime Parkersburg physician,
Dr. Fankhauser was a native of
Vienna who received his medical
degree from the George Washington
University School of Medicine.

Dr. Fankhauser was a U.S. Navy
veteran of World War II and the
Korean War. He served as an
anesthesiologist and obtained the rank
of commander.

During most of his 42-year career,
Dr. Fankhauser practiced medicine
with a specialty in anesthesiology in
the Parkersburg area, serving on the
staffs of St. Joseph’s Hospital and
Camden-Clark Memorial Hospital.

A member of the WVSMA since
1947, Dr. Fankhauser was also a
member of the AMA, Parkersburg
Academy of Medicine and the
American Society of Anesthesiologists.
He held a fellowship in the American
College of Anesthesiology.

Dr. Fankhauser was an avid golfer
and a member of the Parkersburg
Country Club, where he was club
champion and was a former West
Virginia Senior Amateur Champion.

He was a member of First Lutheran
Church, where he served on the
council and taught a Sunday school
class for many years.

Surviving are his wife, Katharine H.
Fankhauser; three sons, Robert
Fankhauser Jr. of Fernadina, Fla.,
William T. Fankhauser of Hilton Head,
and James R. Fankhauser of Vienna;
two daughters, Patricia Smollen of
Canoga Park, Calif., and K. Susan
Fidler of Pittsfield, Mass.; six
grandchildren; three stepgrandchildren;
one stepgreat-granddaughter; and one
sister, Mary Fankhauser Hyland of
Marietta, Ga. He was preceded in
death by three brothers.

Memorials can be made to the First
Lutheran Church, Parkersburg; or the
Central Ohio Parkinson Society Inc.,
3166 Redding Road, Columbus, Ohio
43221-1951; or the charity of the
donor’s choice.

Amitava Ghosal, M.D.

Dr. Amitava Ghosal, of
Morgantown, died December 2.

Robert C. Lincicome, M.D.

Dr. Robert C. Lincicome, of Vienna,
died April 6 at Camden-Clark
Memorial Hospital in Parkersburg.

Dr. Lincicome was born in
Macksburg, Ohio, and received his
pre-med degree from Marietta College
and his medical degree from the Duke
University School of Medicine. From
1939-42, he served on the staff of
Duke University Hospital.

A veteran of World War II, Dr.
Lincicome served in the 65th General
I lospital LInit in England. After his
military duty, Dr. Lincicome moved to
Parkersburg in 1946 and opened his
office. He was chief of anesthesia at
Camden-Clark Memorial Hospital until
his retirement in 1981.

A member of the WVSMA since
1946, Dr. Lincicome was also a
member and past president of the
Parkersburg Academy of Medicine. He
was a member of BPOE 198, American
Legion Post 15, the VFW, and
Westminster Presbyterian Church.

Surviving are his wife, Margaret E.
Garrettson Lincicome; three sons,
Robert D. Lincicome of Vienna,

Charles E. Lincicome of Lewisburg,

Pa., and William C. Lincicome of
Peachtree City, Ga.; three daughters,
Mary Ellen Eddy, Sue Jackson and
Elizabeth Ayre, all of Vienna; 13
grandchildren; and two great-
grandchildren. He was preceded in
death by three brothers and three
sisters.

Memorials are preferred to the
Camden-Clark Memorial Hospital
Foundation or the St. Joseph Hospital
Foundation.

“I want
to live.”

Ashley has cancer. It
sounds like such a grown-up
disease. But each year, more
than 6,000 American children
will be stricken with cancer.

Ashley, and thousands
of others like her, will have a
chance to beat cancer because
of the life-saving research
and treatments developed at
St. Jude Children’s Research
Hospital.

To find out more, write to:
St. Jude Hospital
P.O. Box 3704
Memphis, TN 38103
or call 1-800-877-5833.

ST. JUDE CHILDREN'S
RESEARCH HOSPITAL

■V Danny Thomas. Founder

260 THE WEST VIRGINIA MEDICAL JOURNAL

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

West Virginia

* VVA

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UNIVERSITY OF MARYLAND

&BEWWj?w^ % {/ cg£tf *v 'jan^ JSy*

HUH, SCIENCES LIB.-ACQ. DEPT

ill SOUTH' GREENE STREET

» .•<

BALTIMORE MD 21201

a; JK^Bl > S 1 y* af' ^

WmsIrLM n

bjr;»

Years From Now, Will You Still Be FYotected
For The FYocedures You Perform Today?

Every decision a doctor makes carries a risk.

And you never can tell how many years from now
a claim could arise.

That’s why it’s vital to be insured by a company
that’ll be around to protect you and your practice
years into the future.

CNA has been protecting doctors against
malpractice claims for over 30 continuous years.

A record which demonstrates our dedication to pro-
viding continual coverage even in uncertain times.

For more information about medical malprac-
tice insurance from the CNA Insurance Companies,
contact your local agent or:

McDonough Caperton WVSMA

Insurance Group PO. Box 4106

One Hillcrest Dr. East Charleston, WV 25364

RO. Box 3186 (304)925-0342

Charleston, WV 25332-3186
(304)346-0611

We’re there when you need us most.

The WVSMA/CNA Physicians Protection Program
is underwritten by Continental Casualty Company
one of the CNA Insurance Companies/CNA Plaza/Chicago, IL 60685.

CNA

For All the Commitments You Make®

EDITOR

Stephen D. Ward, M.D.. Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Postmaster send form 3579 to the West
Virginia Medical Journal, 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL IOURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $36 a year in the U.S.;
$60 in foreign countries; $3 per single copy.
Address communications to the West
Virginia Medical Journal, P. O. Box 4106,
Charleston, WV 25364.

Due to increasing publication and mailing
costs, the West Virginia Medical Journal wifi
not honor claims for back issues for any
reason, unless these claims are received
within a 6-month period after issue of the
publication requested.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Road,
Ann Arbor, MI 48106.

1-800-257-4747 or (304) 925-0342

USPS 676 740
ISSN 0043 - 3284

West Virginia Medical

OURNAL

Contents

Feature Article

Dying and death: One physician’s perspective 270

Scientific Newsfront

Computed tomographic diagnosis of acute

blunt pancreatic transection 274

Injury in West Virginia: An introduction to injury

control and prevention 279

Neurologic deficits restored after elective posterior

fossa decompression 284

President’s Page

Just say YES! 288

Editorial

Truth in packaging 289

Letter to the Editor

PA program benefits health care

in West Virginia 290

Special Departments

General News 292

WVSMA Annual Meeting Registration Form 295

Continuing Medical Education 298

Medical Meetings/Poetry Corner 299

Bureau of Public Health News 300

Robert C. Byrd Health Sciences Center of WVU News 302

Marshall University School of Medicine News 304

Medical Student News 306

Advertising Rates 308

Classified 309

July Advertisers 310

Front Cover

Mountain laurel in bloom at Twin Falls State Park in
Wyoming County. Photo courtesy of Scott Durham of
Pineville.

JULY 1994, VOL. 90 269

Dying and death: One physician’s perspective

BRUCE A. FOSTER, M.D.

Family Medicine Practitioner, South Charleston, and Attending
Physician, Kanawha Hospice Care, Inc.

The first problem with the topic of dying and death is
the words. Just scan several dictionaries and you will notice
the definitions all emphasize loss, so it seems very difficult
to take a positive approach. Decease, demise, dissolution,
extinction, departure, loss, passing, lacking power, incapable
of being stirred, grown cold, no longer producing, to pass,
to disappear, to suffer, to cease; these are words we’re
familiar with, but their concepts are too narrow. Their
definitions only focus on the biological aspects of death or
more specifically, dying. To be able to deal effectively with
death and dying, we need to broaden our views to realize
there is much more to these realities of life than loss.

The appreciation of balance between agony (death
struggle) and ecstasy (rapturous delight, a state of trance
produced by an overmastering emotion such as joy or
adoration) is necessary to successfully deal with death and
dying. There is no doubt that dying is not a pleasurable
nor desirable activity for any biological organism; death,
however, can be viewed as a blessing.

A reframing of our traditional ideas is necessary to
realize that there are no deaths, rather graduations to the
next step. This concept is sometimes difficult to grasp
since we have no experience with the next step, and thus
have no sensory data with which we can evaluate it. It is
not just faith that gives us an acceptance of afterlife
experiences; it is the overwhelming similarity in the reports
of afterlife experiences that makes them difficult not to
accept. Even though the word or concepts used to
describe the experience differ depending upon the cultural
context, the uniformity of the graduation encounter cannot
be ignored. We still may not appreciate Einstein’s Theory
of Relativity, but since the transistor radio obviously works
we accept it. This same type of principle must be utilized
to accept the concept of life after death.

Therefore, the givens in the death and dying equation
are these:

( 1 ) Dying is a bitch, but death is a continuation, a new
beginning.

(2) Where we are in our life’s calendar should determine
our approach to dying and death. Early in the spring
and summer of our life, avoid dying; but when we
get to the last weeks of December perhaps consider
embracing death.

Fortunately or unfortunately, activities that surround
dying and death don’t feel natural, since most of us only
get one personal attempt at practice. There are also
tremendous sociocultural pressures to avoid the situation
altogether.

In the dance of dying and death, there are usually three
sets of individuals involved: the one who is dying, their

family members and the health care provider. There are
also three important variations of the dance. When a
person’s ship is sinking and they are in the life raft, the
alternatives are:

(1) Deny the situation.

(2) Paddle like hell until exhausted.

(3) Lay back and go fishing and enjoy the time that is
left. (This is the Hospice concept of care when
dealing with terminal patients.)

liltimately, the patient must be in charge, and be
allowed to choose the variation that makes him or her
most comfortable. Once identified, caregivers and family
should then support the patient’s choice even if it’s not
what they prefer.

As difficult as it is for the patient to accept the reality of
dying and death, it is just as difficult for the family. The
family must be made aware of one constant; that is a roller
coaster of inconsistencies. Family members are not trained,
guided or empowered by experience to know that what
they're trying to do is correct. It is very difficult to find
guidance, but I feel that this poem I wrote two years ago
best expresses how to handle this difficult situation:

To The Family of My Dying Patient

You told me you didn't know what to do;

Here are my suggestions:

Realize that our loved one is dying.

Realize their dying is a graduation to something better.

It’s the only way to get better.

Remember, Spring follows Winter.

Be with them - it’s lonely to die.

Sit with them, touch them, cry with them.

Love them - make them realize they are special.

Review past events, reminisce.

Let them be in charge - follow their choices.

Ask about all the things you're afraid to say.

Deal with the fear of death - with the faith that all will be alright.

Deal with the fear of the situation with knowledge - the truth.
Realize that what you don't do now you can't do later.

And with courage you can do it.

Many caregivers are trained that losing a patient
represents failure; this concept obviously needs to be
re-examined. Most caregiver-patient encounters are not life
and death issues. Fortunately, most of us only encounter
the issue of death once and, therefore, the ethics of dying
and death may not necessarily apply in day-to-day health
issues. However, once the path toward graduation is
certain, the rules change.

Pneumonia is a readily treatable disease. Should
someone in the early non-painful stage of an expectantly
painful disease seek treatment for pneumonia? Should a
terminal cancer patient be artificially fed? Should the
cancer be fed so it can go on longer? These types of

270 THE WEST VIRGINIA MEDICAL JOURNAL

questions cannot be answered since the answers may
change depending upon the belief system of the individual
involved.

Remember, each case is different, so decisions should
not be made in a “one rule fits all approach.” As a
practicing physician, my criteria for a successful graduation
is to have the patient as pain free as possible, content with
their life as it has been, and as accepting as possible of
their graduation -- with the family present so they can
whisper in the patient’s ear they love them as they go.

This concept focuses not on the agony of dying but on the
ecstasy of death.

Once the patient graduates, the reasons for the
definitions of dying and death are now apparent — the
loss. The survivors have loss; the graduate wins. The
survivors need the aftercare. Dealing with grief is difficult,
but if the survivors are allowed to be honest with their
feelings, a resolution through the various stages of grieving
(denial, anger, bargaining, depression and acceptance) will
be obtained.

Resolution is complete when the survivors can balance
the agony of their loss with the ecstasy for the one they

have lost; when they can balance the lack of day-to-day
presence of the individual with the joy of knowing and
appreciating their loved one; when they can feel joy that
their loved one still goes on in the afterlife (whatever that
is); and when they feel the contentment that everyone
participated as they felt they should.

After losing my father to cancer in the early 1990s, his
eyeglasses on my fireplace mantel continue to remind me
of his vision, the annual fruitcake we still send from him
reminds me of his giving nature, and in his old coat I can
always find his smell that reminds me of how blessed I
was to know him.

Acknowledgments

The author wishes to thank Pat Maddox for the fonnat of
this article; Bill French for his feedback; Gary Mears, Ed.D.,
for his concern; Marlise Foster for her patience; and all his
patients for the lessons they teach him every day.

Editor’s Note: Excerpts from this article were
published in the May issue of Palliation, the
newsletter published by Kanawha Hospice Care, Inc.

A Dollar A Day

will help things go your way!

$365 Club

WESPAC has a new club - the $365 Club - or A Dollar A Day. Just think about it, a dollar a day can
better help reform the health care system and protect your rights as physicians as well as the rights of your
patients. Don't wait, the time to act is now!! Send your personal check to WESPAC and become
involved!

WESPAC
P.O. Box 4106
Charleston, WV 25364

JULY 1994, VOL. 90 271

Did The Door
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0WEST VIRGINIA UNIVERSITY SCHOOL OF MEDICINE

Office of Continuing Medical Education

20th Annual Hal Wanger Family Medicine Conference

September 15-17, 1994

Robert C. Byrd Health Sciences Center of West Virginia University
Morgantown, WV

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Computed tomographic diagnosis of acute
blunt pancreatic transection

MARK G. NELSON, M.D.

DAVID R. JONES, M.D
ALEXANDER VASILAKIS, M.D.

GREGORY A. TIMBERLAKE, M.D., F.A.C.S.
Department of Surgery, Robert C. Byrd Health
Sciences Center of West Virginia University,
Morgantown

Abstract

Pancreatic injuries secondary to
blunt trauma are challenging to
diagnose. In many cases, the
diagnosis is missed or delayed due
to the subtle symptoms and signs of
pancreatic injury. Blunt pancreatic
injuries may evolve over a period of
time and can be a source of
extensive morbidity and mortality.
Most radiologic and laboratory
studies have been notoriously non-
specific in diagnosing pancreatic
injuries. This article discusses three
patients we treated with pancreatic
transection secondary to blunt
trauma, who underivent computed
tomography ( CT) of the abdomen on
admission. The pertinent CT findings
and utility of CT as a diagnostic tool
in these three cases of blunt
pancreatic injuries are reviewed.
Abdominal CT scanning can
accurately identify pancreatic
injuries secondary to blunt trauma,
allowing expeditious surgical
intervention. A high index of
suspicion for pancreatic injury
combined with careful interpretation
of abdominal CT scans can provide
valuable information about
pancreatic injury during the initial
trauma assessment.

Introduction

Pancreatic injury from blunt trauma
was first described by Travers in 1827 (1).
Current diagnosis of pancreatic injury,
however, remains a dilemma for the
clinician. Although infrequent, the
presence of pancreatic injury must be
suspected following an accident with
appropriate mechanism of injury.
Approximately 3%- 1 2% of patients

with blunt abdominal trauma will have
pancreatic injuries (1,2,3).

The most common cause of
pancreatic transection is related to
direct steering wheel injury to the mid-
epigastrium (4). The dispersal of
energy to the pancreas overlying the
vertebral column has been identified
as the origin of most mid-pancreatic
injuries (1) (Figure 1). Early diagnosis
of pancreatic injuries is of utmost
importance in preventing the excessive
morbidity and mortality associated
with delayed diagnosis. Early
identification of blunt pancreatic injury
requires a high index of suspicion, a
carefully planned diagnostic approach
and close observation (3). Numerous
diagnostic adjuvants have been
proposed which can assist in the early
diagnosis of pancreatic injury. Many of
these diagnostic studies, however,
have a low specificity and sensitivity.

The purpose of this study is to
review three cases of pancreatic
transection and discuss the use of

computed tomography (CT) in
diagnosing pancreatic injury
secondary to blunt trauma.

First case report

A 59-year-old unrestrained female
driver was involved in a high speed,
head-on, motor vehicle accident. The
car sustained heavy damage including
destruction of the inner compartment
and steering wheel. At the scene, the
patient was hypotensive (80/0 torr),
tachycardic (124 beats/min.), dyspneic,
and complaining of left upper
abdominal and chest pain. Two large
bore intravenous catheters were placed
and fluid resuscitation was begun with
crystalloid solution.

The patient was fully immobilized
and transported by ambulance to Ruby
Memorial Hospital. In the Emergency
Department, resuscitative measures were
continued, blood transfusions begun
and the patient stabilized. A chest
roentgenogram showed multiple left
rib fractures and widened mediastinum.

274 THE WEST VIRGINIA MEDICAL JOURNAL

Figure 2. Case 1 - CT scan revealing transection of the body of the pancreas.

Figure 3- Case 1 — CT scan showing pancreatic edema, loss of pancreatic contour and
pancreatic fracture.

An abdominal CT scan revealed a
left pleural effusion, free intraperitoneal
fluid, a perisplenic hematoma, and
laceration of the body of the pancreas
(Figures 2,3). The patient was
transported immediately to the operating
room. Exploratory laparotomy revealed
a Grade III splenic laceration, 2,000 ml.
of intraperitoneal blood, and mid-
pancreatic crush injury with duct
transection. A splenectomy and distal
pancreatectomy were performed.
Subsequently, an arch aortogram
showed an ascending aortic arch tear
for which she underwent primary
repair.

This patient’s hospital course was
complicated by the development of a
pancreatic fistula which was
successfully treated non-operatively.
She was discharged after two and a
half months.

Second case report

A 34-year-old male sawmill employee
was struck in the left upper abdomen
and left arm by a board ejected with
great force from a cutting machine.
Initial evaluation revealed stable and
normal vital signs. Physical examination
was significant for a 15 cm. transverse,
superficial laceration in the left upper
quadrant, a diffusely tender abdomen,
and an open fracture of the left elbow.
Chest roentgenograms showed a left
pneumothorax for which a closed
tube thoracostomy was placed.

An abdominal CT scan demonstrated
a mass near the splenic hilum, an
edematous pancreatic contour, and
free fluid anterior and medial to the
spleen (Figures 4,5). Exploratory
laparotomy revealed a near total
pancreatic transection, a Grade III
splenic laceration, and a Grade II liver
laceration. Treatment of these injuries
included distal pancreatectomy and
splenectomy. Hemostasis of the liver
laceration was accomplished with
gelfoam, thrombin and electrocautery.
The open left supracondylar humerus
fracture was treated with open
reduction and internal fixation.

Postoperative complications
included a left subphrenic abscess
which required open drainage. This
patient was discharged after a prolonged
hospital course.

Third case report

A 52-year-old female was an
unrestrained driver in a high speed,
single motor vehicle accident.

Extensive vehicle damage was noted,
including marked deformity of the
steering wheel. The patient suffered a

brief loss of consciousness and was
trapped for 20 minutes. Initial vital
signs were blood pressure 80/0 and
pulse was 130 beats/min. Mast
trousers were applied, crystalloid fluid
resuscitation begun, and she was
brought to Ruby Memorial Hospital.

On arrival, this patient’s blood
pressure was 130/90 and the pulse
was 112 beats/min. Initial evaluation
revealed a left flail chest and a soft,
non-tender abdomen. Significant
laboratory data included a hemoglobin

of 12.1 mg./dl. and a serum amylase
of 301 units/dl. Chest roentgenogram
revealed a widened mediastinum. CT
scan of the abdomen and pelvis
demonstrated an irregularity of the
head of the pancreas (Figure 6).

Aortography was performed which
revealed a transected descending
thoracic aorta. She was taken to the
operating room for aortic repair and
repair of an unsuspected diaphragm
rupture. Following surgery, she
required blood transfusions. A repeat

JULY 1994, VOL. 90 275

serum amylase was 111 units/dl.
Repeat abdominal and pelvis CT scan
demonstrated a pancreatic transection,
large retroperitoneal hematoma, and
free intra-peritoneal fluid (Figure 7).

She was returned to the operating
room where a severed portal vein
injury and pancreatic transection were
found. Because of hemodynamic
instability, portal vein venorrhaphy
and drainage of the pancreatic bed
was performed and the patient was
returned to the Surgical ICU for
further stabilization. Subsequently, she
was brought to the operating room
multiple times for pancreatic
debridement. She was discharged after
a prolonged hospital course.

Discussion

Due to the potentially severe
complications of blunt pancreatic
injuries, attempts have been made to
allow quicker and easier pre-operative
diagnosis. Expeditious diagnosis and
early operative intervention are
desirable for several reasons.

Early (< 48 hours post-injury)
morbidity and mortality is generally
due to associated injuries which are
present in 60%-80% of cases (1,2, 3, 4).
Delays in diagnosis can lead to
excessive late (> 48 hours post-injury)
morbidity and mortality related to the
pancreatic injuries alone (5).

Another problem with delayed
diagnosis is that there is an increased
chance of complications such as
fistulas, abscesses, secondary
hemorrhage, pseudocysts and
pancreatitis (4). In fact, a pseudocyst
can develop as early as six days post-
injury if a significant pancreatic injury
is missed (6). In addition, pancreatic
injury may lead to the exudation of
pancreatic juices into nearby tissues
which leads to severe inflammatory
changes, so delays in diagnosis lead
to technically difficult operations.

Numerous diagnostic modalities
exist for the evaluation of pancreatic
injury. Physical examinations often
reveal only subtle abdominal findings.
There may be initial epigastric or
diffuse abdominal pain which is
followed by transient diminution of
symptoms for one to two hours (5,7).
This temporary decrease in pain may
give the examiner a false sense of
security and increase the chance of a
delayed or missed diagnosis of
pancreatic injury (5,7). Furthermore,
even patients with complete
pancreatic duct transection may be
asymptomatic for several weeks after
injury (4). This lack of symptoms is
attributable, in part, to the initial

Figure 5. Case 2 - CT scan demonstrating pancreatic edema, loss of pancreas contour, and
contusion injury in the tail of the pancreas.

confinement of the pancreatic injury
to the retroperitoneum (5).

Associated injuries may distract the
patient and the examiner from the
usually non-specific abdominal
findings of pancreatic injury.

Inactivation of pancreatic enzymes
and glandular secretory inhibition
occurs after pancreatic trauma which
results in further delays in diagnosis (4).
Obviously, a high index of suspicion
is mandatory for proceeding with

Figure 4. Case 2 - CT scan showing fluid in the lesser sac, free abdominal fluid and
pancreatic edema.

276 THE WEST VIRGINIA MEDICAL JOURNAL

further diagnostic evaluation of
pancreatic trauma.

The serum amylase level has been a
controversial diagnostic study in
assessing pancreatic injury. Many
physicians believe the amylase level is
a non-specific and unreliable indicator
of pancreatic injury (7,8,9,10). The
serum amylase may be elevated in
only 48% of patients with pancreatic
trauma (6). In addition, the degree of
serum amylase elevation does not
correlate with the degree of injury' ( 1 ).
More importantly, even with total
disruption of the pancreatic ductal
system, the serum amylase may not
be elevated until 24-48 hours post-
injury' (1). This delayed rise in the
serum amylase forms the basis for
serial serum amylase determinations.

In addition, a persistent elevation of
serum amylase is a stronger indication
of pancreatic injury than an isolated
value (4). This point is exemplified in
the patient described in the third case.

Plain abdominal roentgenograms
are usually performed in stable trauma
patients suspected of having intra-
abdominal injuries. However, plain
radiographs are frequently non-specific
and unrewarding in diagnosing
pancreatic injury (11). Significant
findings are present in only 18% of
cases (7). This lack of diagnostic
specificity is not improved with the
use of oral contrast agents. Diagnostic
peritoneal lavage lacks sensitivity' for
pancreatic injury and may even be
normal in patients with ductal injury
(5,7,9).

CT scan has emerged as the superior
diagnostic modality in pancreatic
trauma. This is due, in part, to the fact
that blunt trauma evaluation remains
the most common indication for initial
CT scan (2). The CT scan has been
regarded as the best method for
diagnosing pancreatic fracture in
adults (12), but CT scan diagnosis of
pancreatic injuries in children may be
more difficult because of their low
amount of retroperitoneal fat which
diminishes the contrast between
structures (13). Of utmost importance
in the selection of patients as candidates
for CT scan for diagnosing pancreatic
injury is hemodynamic stability (8).
Another important feature of CT
scanning is that the sensitivity and
specificity can exceed 80%, but is
dependent on the interpreter and the
quality of the scanner (3).

Numerous CT scan findings are
suggestive of pancreatic injury (Table 1).
Traumatic pancreatitis results in gland
swelling with inflammatory changes in
the peripancreatic fat and mesentery

Figure 6. Case 3 - CT scan showing edema of the head of the pancreas.

SOMATOM PLUS

Figure 7. Case 3 — CT scan showing transection through the neck of the pancreas.

(2,4,11). Other findings include
obliteration of the pancreatic contour,
thickening of Gerota’s fascia, and
exudation of fluid into the anterior
and/or posterior pararenal space and
lesser sac (8,13,14). There may also be

hemorrhage into the peripancreatic
fat, mesocolon and mesentery (2).
Thickening of the left anterior
perirenal fascia is seen in the majority
of cases of fracture of the pancreas
secondary to blunt trauma (12). Several

JULY 1994, VOL. 90 277

of these characteristic CT findings were
found in each of our three patients.

There are disadvantages to CT
scanning in diagnosing pancreatic
injuries (8,15). False positive scans are
often due to a vertical, low density
plane through the neck of the
pancreas (2). This plane results from
fat around mesenteric vessels,
physiologic thinning of the pancreatic
neck, and unopacified proximal
bowel (2). False positive scans can
also result from “streak” artifacts (12).
False negative scans in patients with
pancreatic fracture can be a result of
observer error, too little contrast
medium, hematoma obscuring the
fracture, or close apposition of
fracture margins which “spring” back
together (12).

Another disadvantage is that very
early (< 12 hours) CT scan findings
may be minimal (2), and the scan may
initially be interpreted as normal in
40% of cases (7,15). Major pancreatic
ductal injury can occur without
obvious changes on initial CT scan
(15). Thus, stable patients in whom a
high index of suspicion exists should
have repeat CT scans in 12-24 hours
(2,8). Improvements in diagnosis may
be made with dynamic CT scanning
(2,12) and scanning at 5 mm. slices
(instead of the standard 1.0 cm.) (12).

Endoscopic retrograde
cholangiopancreatography (ERCP) can
play a significant role in diagnosing
pancreatic injuries in the
hemodynamically stable patient (1).
ERCP may supplement or confirm the
diagnosis, particularly in patients with
late (> 48 hours) diagnosis of pancreatic

injury (2,7). ERCP is recommended in
stable patients without peritoneal
signs and with a rising serum amylase
to document the presence of major
pancreatic ductal injury (9).

Ultrasound examinations are generally
felt to be of little benefit in the early
diagnosis of acute pancreatic injury.

Conclusions

The diagnosis of pancreatic injury
due to blunt trauma remains a
challenge for the clinician. Among the
various tools to diagnose pancreatic
injury, CT scanning has proven to be
quite beneficial. An interval CT scan
with close observation of the stable
patient with equivocal findings is
frequently useful.

Despite the diagnostic value of CT
scanning in pancreatic injury,
interpretation of the scan is an
inherent limitation. A high index of
suspicion combined with characteristic
CT scan and physical findings can
afford expeditious assessment and
management of this injury.

References

1 . Frey C. Trauma to the pancreas and
duodenum. In: Blaisedell FC, Trunkey DD,
editors. Trauma management: abdominal
trauma. New York: Thieme-Stratton Inc.,
1982:87-122.

2. Federle MP. Computed tomography of blunt
abdominal trauma. Radiol Clin North Am
1983;21:461-75.

3. Jurkovich GJ, Carrico CJ. Pancreatic trauma.
Surg Clin North Am 1990;70:575-92.

4. Kudsk KA, Temizer D, Ellison EC, Cloutier CT,
Buckley DC, Carey LC. Post-traumatic
pancreatic sequestrum: recognition and
treatment. J Trauma 1986;26:320-4.

5. Linos DA, King RM, Mucha P, Famell MB.
Blunt pancreatic trauma. Minn Med 1983;
66:153-60.

Table 1. CT Signs of Pancreatic Injury

1. Pancreatic edema and loss of contour

lines ,

2. Inflammatory changes in peripancreatic fat
and mesentery

3. Thickening of Gerota’s fascia

4. Exudation of fluid into anterior and
posterior pararenal spaces, and lesser sac

5. Hemorrhage into peripancreatic fat.
mesocolon, and mesentery'

6. Pseudocyst formation

6. Federle MP, Crass RA, Jeffrey RB. Trunkey
DD. Computed tomography in blunt
abdominal trauma. Arch Surg 1982;117;
645-50.

7. Wilson RH, Moorehead RJ. Current
management of trauma to the pancreas. Br
J Surg 1991;78:1196-202.

8. Meredith JW, Trunkey DD. CT scanning in
acute abdominal injuries. Surg Clin North
Am 1988;63:255-68.

9. Jones WG, Finkelstein J, Barie PS. Managing
pancreatic trauma. Infections in Surgery,

Mar 1990:29-35.

10. Wisner DH, Wold RL, Frey CF. Diagnosis
and treatment of pancreatic injuries, an
analysis of management principles. Arch
Surg 1990;125:1109-13.

11. Federle MP, Goldberg HI, Kaiser JA, Moss
AA, Jeffrey RB, Mall JC. Evaluation of
abdominal trauma by computed tomography.
Radiology 1981;138:637-44.

12. Dodds WJ, Taylor AJ, Erickson SJ, Lawson
TL. Traumatic fracture of the pancreas: CT
characteristics. J Comput Assis Tomogr 1990;
14:375-8.

13- Sivit CJ, Eichelberger MR, Taylor GA, Bulas
DI, Gotschall CS, Kushner DC. Blunt
pancreatic trauma in children: CT diagnosis.
Am J Radiol 1992;158:1097-100.

14. Fuchs WA, Robottie G. The diagnosis impact
of computed tomography in blunt abdominal
trauma. Clin Radiol 1983;34:261-5.

15. Sherck JP, McCort JJ, Oakes DD. Computed
tomography in thoracoabdominal trauma. J
Trauma 1984;24:1015-21.

278 THE WEST VIRGINIA MEDICAL JOURNAL

—

Injury in West Virginia: An introduction to
injury control and prevention

MARY ANN BORGMAN, P.A., M.B.A.
Injury Control Fellow

JANET M. WILLIAMS, M.D.

Research Director

JOHN E. PRESCOTT, M.D.

Director, Center for Rural Emergency
Medicine, West Virginia University,
Morgantown

Abstract

Each year, one of every four
Americans sustains an injury severe
enough to seek medical attention.
Injuries account for 25% of all
emergency department visits, 12% of
all hospital admissions, and cost the
nation over $180 billion annually (1).
Despite being the leading cause of
mortality for Americans under the
age of 40, there is a lack of awareness
of the epidemic of injuries and
effective methods for their
prevention. Many consider injuries
to be the result of unavoidable
accidents or unfortunate acts of
God. In reality, injuries are diseases
which have associated risk factors,
demographic distributions, seasonal
variations, epidemic episodes, and
are predictable and preventable.

This article describes injuries in
West Virginia and discusses basic
principles of injury control and
prevention.

Introduction

Injuries are the third leading cause
of all deaths in the United States and
West Virginia. However, injuries are
by far the major cause of deaths among
children and young to middle-aged
adults (1). In fact, for ages one
through 44, injuries surpass both
cancer and heart disease as causes of
death (1) (Figure 1).

Since deaths due to injury’ occur
disproportionately in the young,
comparing the total number of injury
deaths with deaths from other causes
fails to take into account the years of
potential life lost. It is important to
consider how the deaths of so many
young people affect the future. What
might they have contributed? The
effect of this premature mortality is
reflected in the measurement of years
of potential life lost (YPLL) in each
age group before 65 years. Figure 2
shows that injuries are responsible for

more years of potential life lost than
cancer and cardiovascular disease
combined (2).

West Virginia’s death rate

The risk of injury is higher in rural
areas, such as West Virginia, and
among economically disadvantaged
populations (3)- In fact, West Virginia’s
injury fatality rate is greater than the
U.S. rate for all ages and nearly all types
of injury. Nationally, the injury-related
death rate is 62.1 deaths per 100,000
population (all ages); and in West
Virginia, that rate is 69.5 per 100,000
population, which is 13 percent above
the U.S. rate (Figure 3)0).

The fatal injury rate for young adults
ages 25 to 44 in West Virginia exceeds
the nation’s rate by 18 percent, and
the motor vehicle traffic fatality rate
for this age group in West Virginia
surpasses the national figure by 50
percent (4)(Figure 4). In 1992, 29,000
West Virginians experienced a motor
vehicle-related injury' severe enough
to require medical attention (3). This
may be attributable to poor road
conditions and the transportation
hazards associated with West Virginia’s
occupational environments. Other
factors which may account for a higher
motor vehicle injury rate include the
lack of seatbelt legislation until
September 1993 and the sanctioning
of a 65 MPH highway speed limit.

The death rate due to fire and burn
injuries in West Virginia is 30 percent
above the U.S. rate (Figure 3X4). One
study hypothesized that these deaths
are largely due to house fires resulting
from the use of hazardous home
heating systems such as wood stoves,
fireplaces, and space heaters. Over
2,700 individuals in West Virginia were
medically treated for burns during
1992 (3). Many of these injuries and
deaths could have been prevented by
strategies such as installation of smoke
detectors, inspection of home electrical
wiring, and planned escape routes.

The injury process

Injury is defined as any damage to
the human body resulting from acute
exposure to physical energy, or from
the absence of vital entities such as
heat and oxygen. The five forms of
injurious energy are thermal,
mechanical, electrical, radiating and
chemical. Roughly three-fourths of all
injuries are caused by exposure to
mechanical or kinetic energy during
incidents such as motor vehicle
crashes, falls, and firearm discharges.
Examples of injury resulting from a
lack of heat or oxygen are hypothennia
and asphyxiation, respectively.

Epidemiologically, injury may be
defined as a disease resulting from the
interaction of the following three
forces, host, agent and environment
(Figure 5). As illustrated in Table 1, an
analogy has been made between the
behavior of injury and the classic
infectious diseases such as malaria (1).
In the case of injury, the host refers to
the victim, the agent is the energy
involved, and the environment is that
which provides the opportunity for
the agent (energy) to impact the host.
The environment may be either
protective and prevent injury, or
unsafe and promote injury. The vector
refers to the mode by which energy is
transferred to the victim or host. For
example, during a motor vehicle crash,
the automobile is the vector which
transmits physical (kinetic) energy to
the host, or driver.

Injury results when the victim is
exposed to energy that exceeds human
tolerance. In most cases, energy is
transmitted as the victim attempts a
specific task or action. The task
performance refers to how well one
executes an action (such as driving a
car) and the task demand is the skill
required to successfully perform the
task (such as maneuver a curve on an
icy road while driving).

When performance is below the

Table 1. An Etiologic Comparison of Injury and a Classic Infectious Disease

DISEASE

HOST

AGENT

VECTOR/VEHICLE

EXPOSURE EVENT

Malaria

Human

P. Vivax

Mosquito

Mosquito bite

Injury

Human

Kinetic

Motor vehicle

Crash

(Head injury,
for example)

energy

JULY 1994, VOL. 90 279

task demand for the action, uncontrolled
energy is released and may lead to
injury. For example, a drunk driver
may lack the skills necessary to drive
his or her car along a curve in the
road. The resulting crash provides the
opportunity for kinetic energy to
impact the driver and may result in
injury. However, if the environment is
protective, with automobile airbags
and seatbelts, or the road is equipped
with guard rails, injury can be
prevented or the severity of the injury
may be reduced (Figure 6).

Analyzing an injury

Any injury event can be separated
into three phases: pre-injury, injury,
and post-injury. For each phase, host,
vehicle, and environment factors play
a part in the injury event. Pre-injury
factors are those that contribute to or
inhibit the release of the injurious
energy. During the injury phase,
certain factors can affect transmission
of energy to the host. Components of
the post-injury phase impact the
severity and outcome of injury after
the injury event has occurred.

Haddon’s matrix is a tool used for
injury analysis that incorporates the
different factors for each phase of the
injury event. Analyzing an injury using
Haddon’s matrix is a practical way to
identify factors that affect the injury
and show that injuries are the result of
a multitude of causal factors which
occur during various phases of an
injury event. A Haddon’s matrix
analysis of a motor vehicle crash is
illustrated in Figure 7.

Principles of prevention

The aim of injury prevention is to
avert or reduce injury by modifying
transmission of energy to the individual.
Prevention strategies such as wearing
a seatbelt, using motorcycle and
bicycle helmets, and installing smoke
detectors have been shown to reduce
injury morbidity and mortality.

To describe the incidence,
demographic distribution, and the cause
and risk factors of injuries, an injury
surveillance system is utilized. The
ability to adequately identify problem
injuries and high-risk groups is
dependent on the quality of data
collected. Injury surveillance forms the
foundation of injury control and is
necessary to formulate and target
effective prevention strategies. A basic
component of injury surveillance is
the “E-code,” and E-coding is a
standardized method of categorizing
external causes of injury in terms of
how and where the injury occurred.

Figure 1. Death Rates by Cause and Age

Adapted from Baker SP, O'Neill B, Ginsburg MJ, and Li, G, The Injury Fact Book. 1986 statistics,
Oxford University Press, 1992.

Figure 2. Causes of Death and YPLL

Adapted from " Injury 1 Prevention: Meeting the Challenge, ” Centers for Disease Control, 1985
statistics.

Figure 3- Fatal Injury in WV and U.S. (All Ages)

All rates are calculated per 100,000 population. West Virginia denominator = 1,824,710.

U.S. denominator = 245,807,000.

Adapted from "A Comparison of Injury Mortality Rates, ” WV Dept, of Health and Human
Resources, September 1992.

280 THE WEST VIRGINIA MEDICAL JOURNAL

Figure 5. The Injury Epidemiology
Triangle

Host

Agent Environment

Although E-codes are vital in injury
prevention, their use in hospital
discharge and billing is mandated in
only 14 states.

Currently, E-coding is only performed
on a voluntary basis at a small number
of hospitals in West Virginia, so it is
nearly impossible to determine causes
or circumstances for the majority of
injuries. Data on etiology of injury
obtained via E-codes is essential for
designing prevention strategies and
evaluating their effectiveness. A
movement toward mandatory' E-coding
at hospitals in West Virginia was
initiated by the WVU Center for Rural
Emergency Medicine in 1993, but
further advocacy is dramatically needed
so E-coding is made mandatory at all
hospitals in the state.

Interventions

Haddon’s matrix may be used to
identify factors affecting injury, and
many of these factors can be modified
by either educational, enforcement
and engineering interventions which
are aimed at reducing the incidence
and/or severity of injuries.

Interventions may also be classified
as active or passive. Education and
enforcement are examples of active
interventions since they require
people to change their behavior in
order to be protected. Examples
include educational programs on child
safety or laws mandating seatbelt use.
Unfortunately, these efforts are often
ignored by those at highest risk of
injury, such as lower socioeconomic
populations.

Passive interventions provide
automatic protection and are generally
more effective than active interventions
since they do not rely on change in
human behavior. Modifications in
engineering and design of vehicles,
such as airbags and softer dashboards,
are examples of passive interventions
that have been effective in reducing
the incidence and severity of motor
vehicle-related injuries.

Figure 4. Fatal Injury in WV and U.S. Ages 25-44

All rates are calculated per 100,000 population. West Virginia denominator = 528,850.

U.S. denominator = 78,939.000.

Adapted from "A Comparison of Injury Mortality Rates, " WV Dept of Health and Human
Resources, September 1992.

Figure 6. Permissive vs. Protected Environments

When developing injury prevention
programs, the following suggestions
can increase your chances of being
successful:

1. Target efforts toward a problem
which occurs frequently or
results in severe injury in your
community. In some regions, this
may be house fires and for
. others, motor vehicle crashes.

2. Address problem injuries that
have specific, effective
countermeasures. Focus on
limited, concrete solutions to
specific injuries and avoid diffuse,
general approaches. Examples of
specific solutions include smoke
detectors for preventing house fires
and helmets for preventing
bicycle-related head injuries.

JULY 1994, VOL. 90 281

Figure 7. Haddon’s Matrix

Haddon's Matrix

Factors

Phases

Host

Vehicle

Physical

Environment

Sociocultural

Environment

Pre-event

Impaired capacity due
to alcohol, age. poor
vision, fatigue,
inexperience, poor
judgment

Defective parts
(brakes, tires)

Poor maintenance,
dirty windshield/
windows, improper
brake lights, ease of
control, speed of travel

Narrow road shoulder,
poor lighting, road
curvature and gradient,
road surface type,
weather conditions,
divided highway,
visibility of hazards,
signalization

Attitudes about
alcohol, drunk driving
laws, speed limits,
injury prevention
programs.

Event

Tolerance of body to
energy, injury
threshold due to
aging, chronic
disease (osteo-
porosis), etc. Safety
belt use

Placement hardness
and sharpness of
contact surfaces
(dash, steering wheel),
automatic restraints,
vehicle size

Recovery areas, guard
rails, fixed objects
(telephone poles,
trees), median barriers,
embankments

Attitudes about
seatbelt use,
enforcement of child
safety seat laws

Post-event

Extent of injury
sustained,

knowledge of first aid.
physical condition
and age

Fuel system integrity
(bursting gas tank),
entrapment of victim

Access to EMS, quality
of EMS care, availability
of extrication
equipment,

rehabilitation programs

Training of EMS
personnel, trauma
system programs

Results

Physical and mental
impairment

Cost of vehicle repair

Damage to environment

Legal costs, costs to
society (loss of lives
and income)

3. Make the intervention as simple
as possible to increase public
acceptance and minimize misuse.

4. Develop a critical mass of
community awareness through
broad-based grass roots support,
legislation, enforcement, and
professional action. Utilize
affiliations with community leaders
to build injury prevention
coalitions.

5. Promote institutionalization of
programs to last beyond the initial
volunteer effort or temporary grant
funding. Injury prevention programs
need to be permanent fixtures.

The scope of injury prevention and
control extends far beyond surveillance
and prevention of injury, and includes
acute care and rehabilitation of injured
patients. Acute care begins in the field
during prehospital resuscitation and
continues as the patient is treated in the
emergency department, operating room,
and hospital system. The goals of acute
care are to reduce the morbidity and
mortality of injured patients and to
maximize the patient’s physical, social
and mental function.

Rehabilitation begins during acute
care and continues until the patient’s
level of function is maximized — ideally
to pre-injury level. Depending on the
type and severity of injury, physical
therapy or psychiatric care may be
required. Rehabilitative support may
extend beyond the hospital phase and
into the home with household
adjustments such as wheelchair ramps
or widened doorways to allow easier
access for those dependent on
wheelchairs.

The medical professional’s role

There are seven ways that medical
professionals can utilize their knowledge
and influence to help prevent injuries
in their communities and reduce the
severity of injuries that do occur:

1. Treat acutely injured patients.

Prompt recognition and care of
the primary injury and all related
injuries is important to minimize
further damage.

2. Recognize injury as a
community-wide problem.

When a potentially hazardous
condition exists, the community as
a whole is at risk. Since injuries are
more prevalent among the young,
the community suffers tremendous
emotional trauma and bears the
cost of lost productivity, medical
care, long-term rehabilitation,
legal actions, and lost tax revenue.

3. Incorporate injury control into
your everyday practice. By

recognizing injury as a disease,
medical professionals should seek
to identify individuals at high risk
for injury, evaluate the patient's risk
factors, and develop effective
strategies. For example, a child who
is being treated for a cold who lives
in a home with a swimming pool is
at risk for drowning and other pool-
related injuries. Practical prevention
plans include counseling parents on
the importance of swimming
lessons, referral to community
swimming programs, and
information on use of pool covers,
fencing, and water motion alarms.

4. Counsel injured patients on
controlling injury in the future.

No injured patient or his or her
family should leave a health care
facility without a better
understanding of how the injury
could have been prevented. We, as
health care providers, have a
responsibility to counsel our
patients on how to modify risk
factors for future injury (alcohol
abuse, lack of seatbelt use, etc.).

5. Be a leader in injury control
and educate your colleagues.

Injury control principles should be
integrated into continuing medical
education and prevalent in medical
publications. Ample opportunity
exists to educate colleagues on
injury control.

6. Identify new injury patterns in
your community. New injury

patterns may occur that affect
your community or possibly the
nation. Medical professionals can
help by identifying high-risk groups
for these injuries and reporting
cases to medical journals, local
authorities or medical societies.

7. Act as an injury control
advocate in your community.

The medical professional’s role in
the community is unique and
provides an opportunity to act as
a credible, knowledgeable
advocate for injury control through
public speaking, letters to
policymakers, legislative testimony,
media contact, and helping to
educate other professions. Support
for implementation of E-codes at
local hospitals is essential to
injury control.

Conclusions

Injury is a serious problem facing
our state and nation. Through concerted
effort toward injury prevention,
medical professionals can help
improve the lives of West Virginians
and make a positive impact on the
economy of our state. By recognizing
injury as a predictable and preventable
disease process, like heart disease,
health care providers should strive to
identify those at risk of injury and
determine appropriate countermeasures.

282 THE WEST VIRGINIA MEDICAL JOURNAL

Injury" data collection is essential to
understand the causes of injury and to
design prevention strategies. Reporting
the external cause of injury (E-codes)
by all hospitals is needed in order to
provide accurate data for use in
developing and evaluating practical
countermeasures. The medical
professional is in a unique position to
actively support mandatory E-coding
and to practice injury" control principles
on a daily basis.

For more information on injury
control and prevention or about

advocating E-coding, please contact
the WVU Center for Rural Emergency
Medicine at (304) 293-668 2.

References

1. Baker SP, O'Neill B, Ginsburg MJ, and Li G.
The injury fact book. Oxford University Press.
New York, NY 1992.

2. The National Committee for Injury
Prevention and Control. Injury prevention:
meeting the challenge. Oxford University
Press, New York, NY 1989-

3. Foss R. Injury in West Virginia: incidence
and prevention strategies. Presented at the
Annual Meeting of the State Health
Education Council, Davis, WV, April 27, 1993-

4. West Virginia Department of Health and
Human Services, Bureau of Public Health,
Office of Epidemiology and Health
Promotion. WV and the U.S.: a comparison
of injury mortality rates.

5. Gordon JE. The epidemiology of accidents.
AmerJ of Public Health 1949;39:504-15.

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5. References in parentheses numbered consecutively. No
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6. Tables

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All scientific material is reviewed by the Publication
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304-345-7100

William C Morgan, Jr., M.D., F.A.C.S.

Otologist

Diplomate, American Board of Otolaryngology

OTOLOGY: DISEASES & SURGERY OF THE EAR

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JULY 1994, VOL. 90 283

Neurologic deficits restored after elective
posterior fossa decompression

JOHN V. ONESTINGHEL III, M.D.

PGY3 Medicine/Pediatrics, Charleston Area
Medical Center, Charleston

IYAD M, ZEID, M.D.

PGY2 Pediatrics, Charleston Area Medical
Center, Charleston

JOHN H. SCHMIDT III, M.D., F.A.C.S.

Department of Neurosciences, Charleston Area
Medical Center, Charleston

JOSE IRAZUZTA, M.D.

Assistant Professor of Pediatrics. Robert C.

Byrd Health Sciences Center of WVll,
Charleston Division ; and Medical Director,
Pediatric Intensive Care Unit, Women and
Children 's Hospital, Charleston

Abstract

Arnold Chiari malformation is a
condition in which the contents of
the posterior fossa are herniated
below the level of the foramen
magnum, and it occurs in three
basic forms. Patients with this
condition frequently have obstructive
hydrocephalus which requires a
ventriculo-peritoneal shunt. This
article describes the case of a infant
female patient with Atnold Chiari
Type I, who suffered an episode of
acute hydrocephalus and neurologic
deterioration after ventriculo-
peritoneal shunt malformation. A
shunt revision did not reverse her
neurologic deficits, so a posterior
fossa decompression was performed
which did improve her condition.

Introduction

Arnold Chiari malformation is a
condition in which the contents of the
posterior fossa are herniated below the
level of the foramen magnum. These
patients frequently have obstructive
hydrocephalus which requires a
ventriculo-peritoneal shunt.

There are three basic types of Arnold
Chiari malformation, and Type I is
characterized by caudal descent of the
cerebellar tonsils (1). Type II includes
descent of both cerebellar tonsils and
the vennis below the foramen magnum.
Type III malformation is uncommon
and involves caudal displacement of
the cerbellum and the brain stem into
a higher cervical meningocele.

Approximately 5 percent of patients
with Arnold Chiari malformation may
spontaneously experience progressive
neurologic deterioration (2). This

article describes the case of a patient
with Arnold Chiari Type I, who suffered
an episode of acute hydrocephalus
and neurologic deterioration secondary
to ventriculo-peritoneal shunt
malformation. A shunt revision did not
reverse her neurologic deficits. Her
condition improved only after a
posterior fossa decompression was
performed several weeks after the
acute event.

Case report

The patient, a 12-month old female,
had been noted to have a marked
increase in her head circumference at
one week of age. A CT of her head at
that time showed hydrocephalus
involving the lateral ventricles. A
ventriculo-peritoneal shunt was put
into place and she was discharged
from the Neonatal Intensive Care Unit
at Women and Children’s Hospital in
Charleston at three weeks of age. Her
neurologic exam was normal and she
was feeding without difficulties.

At eight months of age, this infant
had been readmitted to the hospital
with lethargy and vomiting. A CT scan
showed bilateral hydrocephalus which
was felt to be secondary to a
malfunction of the shunt. She underwent
revision of the shunt and did well
postoperatively.

Four months later, she was again
brought to the hospital and this time
she was suffering from irritability and
vomiting followed by a generalized
seizure and apnea. After being stabilized,
her shunt was tapped with an opening
pressure of 53 cm./H20 (normal < 15).
The cerebral spinal fluid was drained
until the pressure dropped to 10
cm./H20. A revision of the shunt was
performed within 24 hours. After
surgery, her physical exam revealed
significant quadriparesis, especially of
the upper limbs. She was now drooling
and her cough and gag reflexes were
absent. The patient remained intubated
with a naso-jejunal feeding tube in
place to provide her with nutrition.

Three weeks after surgery, there
was still no improvement in her
neurological deficits. Tracheostomy,
gastric tube placement and Nissen
fundoplication were considered, and
after her naso-jejunal feeding tube was
removed, several studies were
performed.

Barium swallow with video
fluoroscopy showed ineffective
sucking, laryngeal penetration with
almost every swallow and abnormal
emptying of the esophagus. A pH
probe study showed a reflux
frequency of 1.5 episodes/hr. (pH less
than four 6.5 percent of the time).

One episode was associated with
bradycardia. A milk radioisotope scan,
which was performed by placing the
isotope and formula in the stomach by
a nasogastric tube and then removing
the nasogastric tube, showed two
episodes of reflux in addition to some
isotope activity in the lower area of the
left lung demonstrated on late images.
This being consistent with aspiration
from a reflux episode. A fiberoptic
laryngoscopy showed incomplete
closure of the vocal cords and difficulty
in handling secretions in the
hypopharnyx. Electroglottography was
consistent with severe vocal cord
paralysis. Magnetic resonance imaging
(MRI) showed findings consistent with
Arnold Chiari Type I.

Twenty-five days after the
ventriculo-peritoneal shunt revision,
neurologic deficits remained unchanged.
A posterior fossa decompression with
dural patch widening graft placement
and C1-C2 laminectomy was performed
in an attempt to reverse her neurologic
deficits. Within a period of one week,
she was noted to have increased and
more effective movement of her upper
extremities. Her gag and cough reflexes
also returned. The patient was
extubated and was gradually able to
resume oral feedings.

Thirty-three days after surgery, a
repeat barium swallow with video-
fluoroscopy and electroglottography
showed normal results. The pH probe
study showed no gastroesophageal
reflux, and the milk scan did not show
evidence of aspiration. At this patient’s
follow-up appointment when she was
15 months old, her neurological exam
showed mild developmental delay
without focal neurological deficits, and
her brain stem function remained intact.

Discussion

Arnold Chiari Type I may be much
more common in childhood than
suspected. These patients may have a
history of suspected SIDS, recurrent
apnea, recurrent headaches, vomiting,

284 THE WEST VIRGINIA MEDICAL JOURNAL

hydrocephalus, post-shunt procedures,
inability to crawl or sit, neck pain,
scoliosis, torticollis, weakness, ataxia,
vertigo, dysphagia, dysarthria,
incontinence, syncope, paresthesias,
tinnitus and sudden death (3, 4, 5, 6, 7, 8).
Unfortunately, Arnold Chiari Type I is
rarely considered a diagostic possibility
for many of these symptoms.

Since MRI became widely available
in 1985, the diagnosis of Arnold Chiari
malformation has significantly increased.
MRI is now considered the most
reliable and least invasive method for
imaging the brain stem (3,9). It is
imperative that MRI is performed deep
into the vertebral canal and not
stopped at the foramen magnum. The
radiologist and the technician should
be informed that Chiari malformation
is suspected.

The exact mechanism of Arnold
Chiari malformation is not known. It
has been postulated that it may result
from a cranio-cervical growth collision
(10) which displaces the posterior
fossa structures in a caudal direction.
This herniation may also be caused by
pressure gradients between the
cranium and the spine (11). There are
a few described cases of familial
origin, and patients with Arnold Chiari
malformation may remain
asymptomatic for their entire life or
may develop symptoms as late as the
sixth decade.

Approximately 5 percent of patients
with Arnold Chiari malformation will
develop progressive symptoms as a
result of brain stem or cranial nerv e
dysfunction (1). Dysphagia has been
found to be one of the most common
brain stem dysfunctions in Arnold
Chiari Type I and it usually precedes
more severe abnormalities. The
mechanism of the brain stem
dysfunction is theoretically attributed
to several factors including direct
compression, endogenous dysgenesis,
ischemia and adhesion formation
secondary to continuous Ribbing
between the hind brain and the

foramen magnum. Once a patient
with known Arnold Chiari
malformation becomes symptomatic,
surgical suboccipital decompression
should be considered, and in some
cases an anterior transodontial
decompression should precede the
posterior decompression (4).

Dyste and colleagues reviewed 10
years of surgical experience with 50
patients suffering from symptomatic
Arnold Chiari malformations. They
found that after posterior
decompression, 20 percent of the
patients were asymptomatic, 66 percent
improved, 8 percent stabilized, and in
6 percent the disease progressed in
spite of the procedure (4).

Williams reported a series of 46
patients between 1980 and 1989 who
underwent suboccipital craniotomy
and cervical laminectomy for
symptomatic Arnold Chiari. Of these
patients, 15 presented with neurogenic
dysphagia; four of the patients with
mild dysphagia showed rapid
improvement after surgery; and seven
patients with more severe impairment
(but with no other signs of severe brain
stem compromise) also improved but
more slowly. However, the outcome
of the four patients who developed
other severe brain stem dysfunction
before surgery was poor (12). It was
not stated whether these symptoms
were precipitated by an acute episode
of obstructive hydrocephalus.

Conclusions

Our patient had mild developmental
delay without any focal neurological
deficits before her last episode of
ventriculo-peritoneal shunt malfunction,
after which she developed severe brain
stem dysfunction. This most likely
resulted from a mechanical displacement
and compression of the brain stem.
Despite the ventriculo-peritoneal
shunt revision and superior
decompression, she remained
symptomatic with a neurologic lesion

which did not improve after three
weeks.

We postulate that the acute
hydrocephalus produced a mechanical
displacement or impaction of part of
the brain stem that superior
decompression did not relieve. A
posterior fossa decompression was
performed with rapid and complete
neurological recovery.

Thus, we feel that a child who
presents with acute or progressing
neurologic (especially brain stem)
deficits and no obvious cause should
be evaluated for a Chiari malformation.
Significant morbidity may be relieved
or avoided if surgical intervention is
early.

References

1. French BN. Abnormal development of the
central nervous system. In: McLaurin RL,
Venes JL, Schut L, Epstein F, editors.
Pediatric Neurosurgery. 2nd edition.
Philadelphia: W. B. Saunders, 1989;9:34.

2. Putnam PE. Cricopharyngeal dysfuntion
associated with chiari malformations.
Pediatrics 1992;89:871-6.

3. Dure LS, et al. Chiari type I malformation in
children. J Pediatrics 1989;115:573-6.

4. Dyste GN, et al. Symptomatic chiari
malformations: an analysis of presentation,
management, and long-term outcome. J
Neurosurg 1989;71:159-68.

5. Rousseaux M, et al. Syncopes et manifestations
neurologiques transitories revelatrices de
malformations de la chamiere cervico-
occipitale. Semin Hop Paris 1983;59:729-32.

6. Dong M. Arnold chiari malformation type I
appearing after tonsillectomy. Anesthesiology
1987;67:120-2.

7. Ruff ME, et al. Sleep apnea and vocal cord
paralysis to type I chiari malformation.
Pediatrics 1987;80:231-4.

8. Tomaszek DE, et al. Sudden death in a
child with occult hind brain malformation.
Ann Emerg Med 1984;13:136-8.

9. Ishikawa M, et al. Tonsilar herniation on
magnetic resonance imaging. Neurosurgery
1988;22:77-81.

10. Ruth M. Cranio-cervical growth collison:
another explanation of the arnold chiari
malformation and the basilar impression.
Neuroradiology 1986;28:187-94.

11. Pollack IF. Neurogenic dysphagia resulting
from chiari malformations. Neurosurgery
1992;30:709-19.

12. Williams B. Progress in syringomyelia. Neuro
Res 1986;8:130-45.

JULY 1994, VOL. 90 285

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Recently, a call went out from
President-Elect Denny Burton for
requests for committee appointments
to the standing committees of the
WVSMA. This request reminded me of
just how vital it is to have the proper
physician input on our committees in
order to keep the WVSMA a viable
and strong organization.

The Executive Committee alone
cannot possibly cover all the issues
without feedback from committees.
This has been one of the most
frustrating experiences in the past
year for me — knowing that there is
an issue which needs action, but not
having the time to study it properly
and formulate a plan. The committees
who are the strongest and most
successful are those that are the most
active — the Medical Education
Committee, the Insurance Committee,
the Legislative Committee, the
Program Committee for the WVSMA
Mid-Winter Clinical Conference and
the Program Committee for the WVSMA
Annual Meeting.

In order to have a strong committee
structure, the WVSMA provides

Just say YES!

agendas, coordinates meeting dates,
consolidates several meetings on the
same days, and provides research and
clerical support. Efficiency has also
been achieved by regionalizing ad
hoc committees to decrease travel
time, and utilizing the mail and
conference calls as an alternative to
actual meetings.

A committee, though, is only as
good as its leader and its members. A
strong, active chairperson is vital to any
committee’s success so the members
can concentrate on the broad issues;
and the members must contribute
their ideas and their time to help
make the committee a productive one.

Since the committee structure of the
WVSMA branches out from the
Council and reports back this
governing body, it is obvious that the
success of committees is dependent
on an active Council. In an attempt to
increase attendance and help to
strengthen the Council structure, a
change in the bylaws will be
introduced at the WVSMA Annual
Meeting in August to allow for
alternate councilors.

The bottom line is that I am asking
those of you who are not currently
active on one of our committees to
join in and help make our committee
structure more effective. Yes, I know
that the distance to Charleston is a
problem at times and that meetings
are often not convenient, but isn't it
better to be a part of the solution
instead of the problem?

Too often, I hear critism from
members who never participate on
any of the WVSMA committees, or if
they are members, never attend any
of the meetings. If you have a specific
interest or are concerned about an
issue, get involved! Ask us to develop
an ad hoc committee about a particular
subject, agree to be a committee chair,
assist us in building new committees,
or help us maintain the ones that are
already working well. Don't complain
about the way the coach and the team
are playing the game if you aren't
even out on the field with them.

Just say YES when the call comes
for you to participate on a
committee!!!

James L. Comerci, M.D.

288 THE WEST VIRGINIA MEDICAL JOURNAL

Editorial

Truth in packaging

At an early July meeting of the
Senate Finance Committee carried on
C-SPAN, our own Senator Rockefeller
asked for and was given the floor. The
committee was busy “marking up”
Senator Moynihan's compromise
version of a health reform bill, one with
which, from his later continued
trumpeting of Hillary’s original, Senator
Rockefeller had to be displeased.

We are not sure that the senator’s
remarks were pertinent to or reflected
any inclusion in the proposed or final
version of the bill under discussion, but
his remarks were interesting. He began
discussing the need for work force or
professional reform. His remarks
seemed to be directed at the desirability
of stripping medical schools and
training centers in general of funds they
currently receive for postgraduate
training of residents.

According to Senator Rockefeller,
these training centers are turning out
“too many specialists.” In developing
his thesis, he stated that in this country
today, “there are 80,000 too many
specialists.” From this point, he went on
to calculate that since each of these
specialists can be expected to generate
$1 million in medical spending each
year, a grand total of $80 billion in
medical care each year is spent
needlessly. His conclusion seemed to

be that once “a balance” can be
obtained between “generalists and
specialists,” which he indicated would
be about a 50/50 mix, we can save
gobs of money without affecting
quality. He was thanked by the
chairman and the committee went
about its business.

Perhaps unneeded to be spoken is
the need for someone, some
committee, some board or some
tribunal to manage and control a
system such as the good senator
proposes. The elements sound simple
enough — just allot enough training
money for whatever general or
specialty group seems to be in shortest
supply. But what person, committee or
group is smart enough or will have
enough information to make such
judgments? We seem to recall the Soviet
Union having attempted to do similar
things on an even grander scale in the
recent past. Senator Rockefeller is no
admirer of the Soviet system, but he
should be able to leam from their
failures.

A particular point of curiosity is an
answer to the question. “What is to
replace the yearly work output of those
80,000 specialists to be excluded from
the system?” It is easy enough to
envision a rationing system wherein
there will be certain eligibility

qualifications for any procedure or the
use of any uncommon drug — the
British Health System is replete with
such qualifications. Most specialists are
involved with multiple diseases,
conditions and age groups. To simply
do away with any given number of
specialists or randomly chosen field of
specialty would thus ration and
penalize members of all age groups
and individuals with every known type
of disease or medical condition.

Perhaps this is what our senator has
in mind. With the years of study he
professes to have devoted to medical
care problems, West Virginians and the
nation as a whole deserve better of him
than this. If he believes rationing,
draconian or otherwise, is necessary to
keep the nation out of bankaiptcy, he
should be forthright enough to give his
opinion out loud.

West Virginians who choose to listen
to Senator Rockefeller’s advice on
medical care reform deserve to know
the whole truth. They need to know
the nature and the quality of the goods
they are buying. We need a little taith
in packaging on this issue from the
senator.

Stephen D. Ward, M.D.

Editor

JULY 1994, VOL. 90 289

Letter to the Editor

PA program benefits health care in West Virginia

Adequate health care for many
West Virginians is lacking or at
best difficult to find, especially in rural
areas. West Virginia ranks 48th in the
nation in availability of health care,
and 42 of West Virginia’s 55 counties
are designated as health professional
shortage areas by the federal
government. Physicians in many rural
practices are often overworked and
are unable to keep up with the
demands for health care.

In the 1960s, physician assistant
education was developed in the
United States in order to train military
corpsmen and medics for civilian
practice. It has become a well-defined
curriculum to train students as mid-level
practitioners on the health care team,
and is based on the following goals:

(1) To augment the capabilities of
primary care physicians;

(2) To fill service gaps resulting from
geographic and specialty
maldistribution of physicians; and

(3) To help control health care
costs (1).

Alderson-Broaddus College in
Phillipi, W.Va., helped pioneer the
education of PAs by admitting its first
class in 1968, and being the first college
to offer a bachelor of science degree
in this profession. Alderson-Broaddus
has graduated more than 700 PAs, and
currently, 65% of all practicing PAs in
West Virginia are graduates of
Alderson-Broaddus College.

Over the years, PAs have found
their way into a variety of practices.
They function as physician extenders
in both primary care and specialty
practices. They offer primary care in
many rural communities, and many
work in hospital emergency
departments and clinics. Unlike nurse
practitioners and some other mid-level
practitioners who practice
independently, PAs practice directly
with and under the supervision of
physicians. They are team players.

In order to better respond to the
state’s health care needs, Alderson-
Broaddus College is expanding its
entering class size by 50 students
through a cooperative program with

the West Virginia University School of
Medicine. In the last few years, master’s
degree programs were established in
rural health care and emergency
medicine. Alderson-Broaddus now
offers the first master’s degree
program in the nation for physician
assistants, and 40 students will be
enrolled in these programs in the fall.

As physicians, we should be
cognizant of the continuing
contributions of Alderson-Broaddus
College to health care in West
Virginia. It is a dedicated member of
our medical education team.

James L. Bryant, M.D., F.A.C.S.

Clarksburg

1. JAMA, April 27, 1994:1266-72.

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At Alliance’s Annual Meeting

AMAA, SMAA leaders to be keynote speakers

Barbara Tippins, president of the
AMA Alliance, and Mildred Taylor,
president of the SMA Auxiliary, will
headline the program at the WVSMA
Alliance’s 70th Annual Meeting at The
Greenbrier, August f9-20.

Mrs. Taylor will address the WVSMAA
members on Friday, August 19 during
the First Session of the House of
Delegates, and Mrs. Tippins will speak
on Saturday, August 20 during the
Second Session of the House of
Delegates. At the conclusion of the
Second Session, Mrs. Tippins will
install Sue Bryant of Bridgeport as
president of the WVSMAA for 1994-95.

This year, the format for the meeting
been shortened to two days, and
WVSMAA President Carole Scaring will
be presiding over all of the business
meetings. Brief biographical information
about Mrs. Tippins, Mrs. Taylor and
Mrs. Bryant begins below, and
additional details about the meeting
can be obtained by contacting Winnie
Morano, executive secretary of the
WVSMAA, at (304) 925-0342.

AMAA, SMA leaders profiled

Mrs. Tippins , of Dunwoody, Ga., was
installed as president of the AMA
Alliance in June. She had previously
served at the national level as field
director; chairman and member of the
Health Projects Committee; director;
and as a member of the Nominating
and Bylaws Committee.

In addition to serving in numerous
positions for her state and county
medical alliances, Mrs. Tippins has
been president of both of these
organizations. Most recently, she served
on the Family Violence Committee for
the DeKalb County Alliance, and as
chairman of the Bylaws and Revision
Committee for the Georgia Medical
Alliance. The first Medical Association
of Georgia Alliance member to chair a
Medical Association of Georgia
committee, Mrs. Tippins was chair of
MAG’s Adolescent Health Committee.

Mrs. Tippins has a bachelor of
science degree in home economics
from Georgia State College for Women.
Prior to her marriage to William C.

Tippins Taylor

Tippins Jr., M.D., an obstetrician-
gynecologist, she taught home
economics and kindergarten. The
Tippins have two children and Mrs.
Tippins is also active in many
volunteer and civic organizations.

Mis. Ta ylor attended Chatham College
in Pittsburgh and received a bachelor
of science degree and a master’s
degree in speech pathology from Case
Western Reserve University in
Cleveland. After graduate school, she
was an instructor in speech pathology,
phonics and voice and diction at St.
Louis University.

She married her husband, Charles,
when he was in medical school at
Washington University in St. Louis.
They relocated from St. Louis to
Portland, Maine, where she was active
in the Junior League and with the
United Cerebral Palsy Foundation

Scaring

assisting children and adults with
language-related disabilities. The Taylors
then moved to New Hampshire and
during their years there she worked as
a coordinator for special language
programs for her school district, as a
continuity instructor at the New
Hampshire School for the Retarded,
and as a speech pathology consultant.

The Taylors now reside in Columbia,
Md., where Mrs. Taylor has been very
active in both the state and her local
medical auxiliaries. She also has been
on the Executive Council of the SMA
Auxiliary for over four years and has
held many offices in this organization.

The Taylors have four children and
four grandchildren. Mrs. Taylor is a
member of the Alexandria Choral
Society, which has performed in
several countries abroad.

0 Continued on page 294)

WVSMA Alliance Annual Meeting Highlights

Friday, August 19

10 a.m.

Pre-Convention Board Meeting

12:30 p.m. - 1 :30 p.m.

President’s Luncheon

2 p.m.

WVSMAA House of Delegates First Session

6:30 p.m. - 7:30 p.m.

Reception hosted by CNA/Acordia of West Virginia

9 p.m.

Saturday, August 20

Entertainment - “Good Time Jazz Band” and Pat
Leimbach, humorist

8 a.m.

Past Presidents' Breakfast

9:30 a.m.

WVSMAA House of Delegates Second Session
Installation of 1994-95 WVSMA Alliance Officers

12:30 p.m.

Post Convention Board Luncheon

2 p.m.

Golf and Tennis Tournaments

Bryant

292 THE WEST VIRGINIA MEDICAL JOURNAL

WVSMA Annual Meeting Highlights

Tuesday, August 16

6 p.m.

WVSMA Executive Committee Meeting

Wednesday, August 17

8 a.m.

WVSMA Executive Committee Meeting

1 1:30 a.m. - 1:30 p.m.

Executive Committee/Council Luncheon

1:30 p.m. - 4:30 p.m.

WVSMA Council Meeting

6:30 p.m. - 7:30 p.m.

Presidential Reception, hosted by the P.l.E. Mutual Insurance Company

Thursday, August 18

8:30 a.m. - noon

General Scientific Session

“Peripheral Vascular Disease - Prevention, Medical/Surgical Management and Rehabilitation”

John D. Holloway, MD, Moderator

William F. Ruschhaupt, MD. Cleveland Clinic; Jeffrey W. Olin, DO, Cleveland Clinic; Doug Phillips, MD.
University of Virginia; and Peter Kim Nelson, MD, New York University Medical Center; Panelists

Noon - 1:30 p.m.

Lunch and Learn

“Managed Care . . . Minimizing the Risks,” Jan Woerth. Ph.D., and a panel of visiting dignitaries

1 p.m. - 5 p.m.

WV Section of the American College of Obstetrics & Gynecology

2 p.m.

Golf, Tennis and Volleyball Tournaments

4 p.m. - 5:50 p.m.

1995 Annual Program Committee Meeting

6:30 p.m. - 7:30 p.m.

Reception, hosted by CNA/Acordia of West Virginia

Friday, August 19

7:30 a.m.

Breakfast Meetings

WVSMA Surgery Section Breakfast

8:00 a.m.

WVSMA Dermatological Society Business/Scientific Meeting

8:30 a.m.

First Session of the WVSMA House of Delegates

Edmund B. Flink Address - Richard S. Lang, MD, MPH, FACP, Cleveland Clinic

Thomas L. Harris Address - John J. Bergan. MD, FACS, HON, FRCS(ENG), University of California - San Diego
Business Meeting

Presidential Address - James L. Comerci, MD

10:30 a.m. - 4 p.m.

WVMI Board of Trustees’ Meeting

Noon - 1:30 p.m.

WVSMA Cancer Committee - Business Luncheon

Noon - 1:30 p.m.

Lunch and Learn

“The Shifting Winds of Quality Oversight,’ Harry S. Weeks Jr., MD; Mark K. Stephens, MD; and a
panel of visiting dignitaries

Noon

Specialty Meetings

Noon - 2:00 p.m.

WV Chapter of American Academy of Pediatrics

Noon - 4:30 p.m.

WV Psychiatric Association - Luncheon

12:30 p.m. - 2 p.m.

WVSMA Publication Committee - Luncheon

1 p.m. - 5 p.m.

American College of Obstetrics & Gynecology WV Section

1 p.m. - 4 p.m.

W Orthopedic Society

1:30 p.m.

WESPAC Board Meeting (immediately following Lunch and Learn)

1:30 p.m.

Resolutions Committee - Open Session

6 p.m. - 7 p.m.

Reception hosted by WVU/MU Schools of Medicine, WVU and MCV Alumni

9 p.m. - midnight

Entertainment - Dance to the music of "Good Time Jazz” and enjoy the wit of Author-Humorist Pat Leimbach
(Informal attire) - Chesapeake Hall

Saturday, August 20

7:30 a.m.

Breakfast Meetings

7:30 a.m. - 8:30 a.m.

Ohio County Medical Society and representatives from the Northern Panhandle

7:30 a.m.

Kanawha County Medical Society

7:30 a.m.

Young Physician Section

7:30 a.m.

WV Radiological Society

8:00 a.m.

WV Dermatological Society

8:00 a.m.

Delegate Registration

8:30 a.m.

Second Session of the WVSMA House of Delegates

9:00 a.m.

AMA Presidential Address - Robert E. McAfee, President, American Medical Association

11:30 a.m. - 1:30 p.m.

WVSMA 50- Year Graduates, Past Presidents, Visiting State Presidents and
Component/Speciality Society Presidents' Luncheon

1:30 p.m.

Reconvene Second Session of the WVSMA House of Delegates (business continued)

Oath of Office and WVSMA Presidential Address - Dennis M. Burton, MD

4 p.m. - 5 p.m.

Reception honoring newly-installed officers of WVSMA and Alliance
Hosted by Cabell County Medical Society

JULY 1994, VOL. 90 293

Noted vascular surgeon to speak at Surgery Section meeting

JohnJ. Bergan, M.D., F.A.C.S.,

HON., F.R.C.S.CENG.), a clinical
professor of surgery at the University
of California in San Diego is the
featured lecturer for this year’s WVSMA
Surgery Section Breakfast Meeting on
Friday, August 19 at 7:30 a.m. during
the WVSMA’s Annual Meeting at The
Greenbrier.

The topic for Dr. Bergan’s lecture
will be “ Advances in Treatment of
Varicosities and Telangiectasis. ”
Following the Surgery Section
Breakfast Meeting at 10:45 a.m., Dr.
Bergan will deliver the Thomas L.
Harris Address, "Current Management
of Extracranial Cerebral Vascular
Disease , ” during the First Session of
the House of Delegates. Dr. Thomas
H. Chang, chairman of the WVSMA
Surgery Section, is encouraging all
interested surgeons and physicians to
attend both of these presentations.

Early research interests in
pancreatitis led Dr. Bergan to
explorations of vascular injury in this
condition and then to the study of

Bergan

intestinal ischemia. This area of
research continued to be Dr. Bergan’s
major interest, but he also began
studying renal transplantation,
pancreatic transplantation, and liver
preservation. As a result of his research
activities, he was appointed chief of
transplantation at Northwestern
University Medical School in 1969,
and director of the Organ Transplant
Registry at the American College of
Surgeons in 1970.

meetings of the Society for Vascular
Surgery and the International Society
for Cardiovascular Surgery, North
American Chapter. Dr. Bergan was
also instrumental in the formation of
the Midwestern Vascular Surgery
Society and the American Venous
Forum.

In 1989, Dr. Bergan was named to
his current position as a clinical
professor of surgery at the University
of California at San Diego. That same
year, he also assumed his other two
current posts as a clinical professor of
surgery at the Uniformed Services
University of the Health Sciences in
Washington, D.C., and as an
academic consultant in vascular
surgery at Balboa Naval Hospital in
San Diego.

During his career, Dr. Bergan has
received numerous honors, including
being awarded the Rovsing Silver
Medal of the Danish Surgical Society
and honorary memberships in the
Royal College of Surgeons in England,
the Vascular Society of Great Britain
and Ireland, and the Vascular Surgery
Section of the Royal Australasian
College of Surgeons. He is a past
president of the Society for Vascular
Surgery, the European-American
Venous Symposium, the American
Venous Forum, the International
Association of Vascular Surgeons, the
Chicago Surgical Society, and the Gulf
Coast Vascular Society.

To make reservations to attend the
WVSMA Surgery Section Breakfast
Meeting, please contact Nancie
Diwens at (304) 925-0342.

0 Continued from page 292)

New president highlighted

Mrs. Bryant has a bachelor of
science degree in education, math and
music from West Virginia University.
She has worked with children and
young people in a variety of
organizations, and in 1985 she was
the recipient of the Concern for Kids
Award, which is presented by the
Bridgeport Junior Women’s Club.

Veiy active in her church, Mrs.
Bryant currently directs two children’s
musical drama programs each year,
and is assistant director of the adult

choir, a teacher for an adult Sunday
School class, chairman of the board of
Christian Education, and a member of
the Executive Council. Mrs. Bryant is a
member of the board of directors for
Health Access, Inc., Clarksburg’s free
clinic, and has been an independent
travel agent for the past three and a
half years.

Mrs. Bryant is the wife of James L.
Bryant, M.D., the junior councilor at
large for the WVSMA. The Bryants are
the parents of two daughters and two
sons, and have five grandsons. Mrs.
Bryant's hobbies include traveling,
cooking, sewing, crocheting and
participating in community theater.

Ohio State plans internal
medicine conference

The Seventh Annual Update in
Internal Medicine will be conducted
in Columbus from September 10-13
by the Ohio State Department of
Internal Medicine and the Center for
CME at LIniversity Medical Center.

This course will feature discussions by
Ohio State faculty members about
many areas of internal medicine.

The program meets the criteria for
31 hours in Category I of the Physicians
Recognition Award of the AMA and
the AAFP.

For details, phone 1-800-752-8606.

294 THE WEST VIRGINIA MEDICAL JOURNAL

The West Virginia State Medical Association’ s

August 17-20, 1994

The Greenbrier

White Sulphur Springs, West Virginia

/ Sign Up NOW!

Please be sure to make hotel reservations in advance by calling 1-800-624-6070. The Greenbrier
will fill up quickly because the State Fair will be going on during the same week.

1994 Annual Meeting

Name

Address

City State Zip Code

Specialty

Phone

Payment by: Check _ Visa MasterCard

Conference Cost:

WVSMA member

$125 .

non-member

$175

Additional:

Thursday, Aug. 18
Learn and Learn

member/non-member

$40

(CME Credit)

spouse/ student

$25

Friday, Aug. 19
Lunch and Learn
(CME Credit)

member/ non-member

$40

spouse/ student

$ 25

TOTAL:

Card Number

Expiration Date
Signature

If paying by check, please send registration form and check to:
West Virginia State Medical Association
P.O. Box 4106, Charleston, WV 25364

At the WVSMA’s Annual Meeting

Lunch & Learn

“Managed Care . . . Minimizing the Risks”

Thursday , August 18 at Noon
in the Crystal Room at The Greenbrier

* Featuring*

Jan Woerth, Ph.D.

President ofJ.K. Woerth, Inc.

With Special Guest Panelists

Robert E. McAfee, M.D.

President of the American Medical Association

Donald H. Dembo, M.D.

President of the Medical & Chirnrgical Faculty
of the State of Maryland

Claire V. Wolfe, M.D.

President of the Ohio State Medical Association

Martin A. Murcek, M.D.

President of the Pennsylvania Medical Society

James A. Shield Jr., M.D.

President of the Medical Society of Virginia

CME Offered!!!

Name

Address

Phone

CME Credit

Member/Non-Member - $40.

Spouse/Student - $25.

At the WVSMA’s Annual Meeting

Lunch & Learn

“The Shifting Winds of Quality Oversight”

Friday , August 19 at Noon
in the Chesapeake Hall at The Greenbrier

* Featuring *

Harry S. Weeks Jr., M.D.

President and Director of the West Virginia Medical Institute

Mark K. Stephens, M.D.

Principal Clinical Coordinator for the West Virginia Medical Institute's
Health Care Quality Improvement Program

With Special Guest Panelists

Robert E. McAfee, M.D.

President of the American Medical Association

Ardis D. Hoven, M.D.

President of the Kentucky Medical Association

Donald H. Dembo, M.D.

President of the Medical & Chirurgical Faculty
of the State of Maryland

Claire V. Wolfe, M.D.

President of the Ohio State Medical Association

Martin A. Murcek, M.D.

President of the Pennsylvania Medical Society

James A. Shield Jr., M.D.

President of the Medical Society of Virginia

CME Offered!!!

Name

Address

Phone

CME Credit

Member/Non-Member - $40.

Spouse/Student - $25

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Robert C Byrd Health Sciences
Center of WVU - Morgantown

August 18-20

“Total Joint Arthroplasty: Current
Issues, Concepts and Considerations”
(sponsored by the WVU Dept, of
Orthopedics), Tamarron Resort,
Durango, Colo.

August 27

“Managed Care in the 90s,” The
Marriott Marquis, New York, NY*

September 9

“Inaugural John E. Jones Symposium
on Health Policy” (sponsored by the
WVU Office of the Dean), Robert C.
Byrd HSC of WVU, Morgantown

September 15-17

“20th Annual Hal Wanger Family
Medicine Conference” (sponsored by
the WVU Dept, of Family Medicine),
Robert C. Byrd HSC of WVU,
Morgantown*

September 23-24

“The 15th Annual Clinical
Ophthalmology Conference”
(sponsored by WVU Dept, of
Ophthalmology and the WV
Academy of Ophthalmology),
Lakeview Resort and Conference
Center, Morgantown

*Held in conjunction with a WVU football game

West Virginia State Medical
Association - Charleston

August 13

“Level One Loss Prevention,” Beckley
Hotel, Beckley

August 17-20

“WVSMA’s 127th Annual Meeting,”
The Greenbrier, White Sulphur
Springs

August 27

“Marbury vs. Madison,” Radisson
Hotel, Huntington

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Beckley □ Beckley Hospital, Aug. 3,

6:15 p.m., “Medical Ethics,” Warren
Point, M.D.

Fairmont ★ Fainnont General Hospital,
Aug. 2, 7:30 p.m. “Multiple Myeloma,”
Miklos Auber, M.D.

Fairmont ★ Fainnont Clinic, Aug. 17,

1 p.m., “Jaundice in the Newborn,"
Pam Quarantillo, M.D.

Gassaway □ Braxton County Memorial
Hospital, Aug. 24, 6:30 p.m.*

Madison □ Boone Memorial Hospital,
Aug. 9, 6:30 p.m., “Common
Dennatosis,” Donald Fanner, M.D.

Man □ Man Appalachian Regional
Hospital, Aug. 17, 6:30 p.m., “Urinary
Tract Infections in the Elderly,”
Lawrence Wyner, M.D.

Martinsburg ★ VA Medical Center,

Sept. 1, 3 p.m., “Sleep Disorders,”
Robert Keefover, M.D.

Montgomery □ Montgomery’ General
Hospital, Aug. 3, noon, “Parkinson’s
Disease,” Albert Heck, M.D.

New Martinsville ★ Wetzel County
Hospital, Aug. 11, noon, “Lymphoma,”
Paolo Romero, M.D.

★ Wetzel County Hospital, Sept. 8,
noon, “Hepatitis,” R. Wesley Farr, M.D.

Philippi ★ Broaddus Hospital, Aug. 4,

1 p.m., “Alzheimer’s Disease,”

William Cutlip II, M.D.

Point Pleasant □ Pleasant Valley
Hospital, Aug. 25, noon,

“Cryosurgical Ablation of the
Prostate,” James P. Tierney, D.O.

Richwood □ Richwood Area Medical
Center, Aug. 11, 5: 15 p.m.,
“Management of Low Back Pain,”
Kenneth Wright, M.D.

Ripley □ Jackson General Hospital,

Aug. 12, 12:15 p.m., “Chest Trauma,”
Frank C. Lucente, M.D.

White Sulphur Springs ★ The

Greenbrier Clinic, Aug. 22, 4 p.m.
“Prostate Cancer Prevention Trial,”
Unyime Nseyo, M.D.

★ The Greenbrier Clinic, Sept. 26,

4 p.m., “Breast Cancer,” Edward
Crowell, M.D.

* 7o be announced

THERE’S NOTHING
MIGHTIER THAN THE SWORD

AMERICAN
V CANCER
* SOCIETY

FOR MORE INFORMATION CALL THE AMERICAN CANCER SOCIETY TOLL FREE: 1-800-ACS-2345

298 THE WEST VIRGINIA MEDICAL JOURNAL

Poetry Corner

August

5-6-Quality Improvement in Healthcare: An
Introduction (sponsored by the National
Association for Healthcare Quality), Chicago

5- 7— 2nd Annual Conference of Civil War
Medicine (sponsored by the National
Museum of Civil War Medicine), Frederick,
Md.

8-10-American Hospital Association, Dallas
14-17— Midwest Surgical Association,
MacKinac Island, Mich.

17-20-WVSMA's 127th Annual Meeting,
White Sulphur Springs
19-20-Healthcare Quality Management:
Review and Study Session (sponsored by
the National Association for Healthcare
Quality), Boston

19-20-Communication Approaches for
Tracheostomized and Ventilator Dependent
Patients (sponsored by Voicing!, Inc.)

Chapel Hill, N.C.

25- 27-Southem Association for Oncology,
Sea Island, Ga.

26- 27-Case Management and Utilization
Management in a Changing Healthcare
Environment (sponsored by the National
Association for Healthcare Quality),
Pittsburgh

September

6- 11— 18th Annual Meeting of the American
Academy of Neurological and Orthopaedic
Surgeons, Las Vegas

8-10-American Gynecological and
Obstetrical Society, Hot Springs, Va.

10- 13-Seventh Annual Update in Internal
Medicine (sponsored by Ohio State
University), Columbus

11- 14— American College of Emergency
Physicians, Orlando, Fla.
16-17-Communication Approaches for
Tracheostomized and Ventilator Dependent
Patients (sponsored by Voicing!, Inc.),
Louisville, Ky.

22- 25-American Academy of Family
Physicians, Boston

23- 24— Prevention of Target Organ Damage
in the Hypertensive (sponsored by Ohio
State University), Columbus

23- 24— Transfusion Medicine of the Future
(sponsored by the American Association of
Blood Banks), Phoenix, Ariz.

24- 30-XTV FIGO World Congress, Montreal

For More Information . . .

Contact the Journal at (304) 925-0342.

Seeking Knowledge

Seeking knowledge in a world
In which new knowledge spreads
In ever more expanding ways
Becomes a necessary fact of life.

To just stand still, ignoring growth,

Can leave one not just holding place,

But falling back and losing pace,

While getting out of step with those
Who see a need to move ahead, to grow;

To seek each moment opportune;

Take time to learn, to keep attune.

E. Leon Linger, M.D.

Please address your submissions for Poetry’ Comer to Stephen D. Ward, M.D. ,
Editor, West Virginia Medical Journal P. O. Box 4106, Charleston, WV 25364.

" THAT'S NOT A HAIR 0N\ TOP of DR. CLA&HORN’^

Head... xys> a short fuse1. "

JULY 1994, VOL. 90 299

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health

Ten communities
receive grants to create
wellness programs

Ten community groups in the state
have been awarded one-year grants
from the Bureau of Public Health to
conduct projects designed to improve
the health of West Virginians.

The projects, funded through the
Bureau’s Community Health Promotion
Program, total approximately $20,000
and include the following activities:

"The Brooke County Health
Department, the Mercer County
Board of Health, and Pleasants
County Committee on Family
Issues will assess community
health needs and develop projects
based on identified needs;

"Clay Organized for Wellness will
sponsor various physical fitness
activities for students and area
residents;

"Doddridge County Planned
Approach to Community Health
(PATCH) will evaluate completed
health promotion projects and
reassess future health priorities;

The Randolph-Elkins Health
Department will develop worksite
wellness programs for several area
businesses;

"The E.A. Hawse Health Center in
Baker will provide evening
wellness programs at East Hardy
High School;

*St. George Medical Clinic in Tucker
County will provide exercise
programs for children, ages five
and under, and their parents;

"Ritchie County PATCH will
coordinate nutrition education for
middle school students;

"Monroe Health Center will work
with county agencies and schools
to provide driver’s education and
accident prevention programs.

The Community Health Promotion
Program provides communities
around the state with skills and
resources to make informed decisions
about allocating health resources. The
program also helps to determine
health problems and needs at the
local level and to implement health
programs and services. Currently, 30
of the state’s 55 counties have created
community health promotion sites,
and efforts are underway to expand
to every county by the year 2000.

For more details, call (304) 558-0644.

WVTCC outlines plans
for decreasing tobacco
usage in West Virginia

According to the recently released
report by the West Virginia Tobacco
Control Coalition, “ Five Years Toward a
Tobacco-Free West Virginia, ” many
measures will be taken during the next
five years to dramatically curb the use
of tobacco in the state. These actions,
which will be taken by community
leaders, health care providers and
individual citizens, include passing
clean indoor air regulations, increasing
efforts to help patients stop smoking,
and enforcing laws to prohibit the sale
of tobacco products to minors.

Currently, nearly one-third of all
West Virginians use some type of
tobacco product, and the WVTCC’s
objective is to reduce this to 17% of the
state population by 1998. To achieve
their goals, the WVTCC’s report
emphasizes the need to target groups
that have high tobacco-use rates or low
quitting rates. Plans also call for raising
the tax on cigarettes, restricting tobacco
advertising and promotional events,
increasing the number of worksites that
prohibit tobacco use, and requiring a
license to sell tobacco products.

Ten counties and five communities
have passed clean indoor air laws or
ordinances, and many others are trying
to achieve these goals. A statewide
clean indoor air bill passed the House
of Delegates for the first time this year,
but was not acted upon by the Senate.
Legislation to control tobacco will
again be introduced in January 1995.

For more information, contact the
Joyce Holmes at (304) 558-0644.

New report details
affects of violence
during pregnancy

A study of pregnant, low-income
women in the state shows that
violence during pregnancy affects not
only the abused women, but also their
babies. According to the study, the
unborn babies of women who are
physically abused during pregnancy
were almost four times more likely to
suffer fetal distress or die before birth,
and were three times more likely to
remain in the hospital after the mother
was discharged.

The study was conducted by
interviewing participants in the West
Virginia Bureau of Public Health’s
(WVBPH) Office of Maternal and Child
Health Right From the Start Program
(OMCH/RFTS) during 1991 and 1992.

It was one of the first reports to show
that violence against women during
pregnancy can hurt the unborn child.
Other studies have shown that
violence against women escalates
during pregnancy and may not even
begin until a woman becomes
pregnant. One of every six women
taking part in the new study indicated
she’d been abused during her current
pregnancy, yet the authors believe the
number of unreported acts of violence
against pregnant women is higher. In
nearly 80% of the cases in this latest
study, the woman’s prenatal doctor did
not detect that the woman had been
abused.

The findings were published in a
paper entitled “ Violence, Pregnancy,
and Birth Outcome in Appalachia," by
Dr. Timothy Dye, fonner director of
the WVBPH, Division of Research and
Evaluation of the OMCH. The paper
was co-authored by Nancy J. Tolliver,
R.N., M.S.I.R., deputy director of the
WVBPH; Dr. Richard Lee, head of the
Division of Geographic Medicine at the
State University of New York at
Buffalo; and Catherine Taylor, M.S.W.,
fonner director of the OMCH/RFTS
program of the WVBPH. Dr. Dye
recently presented this paper at the
American Psychological Association
Conference on Women’s Health.

For more information, call Nancy
Tolliver at (304) 558-2971.

300 THE WEST VIRGINIA MEDICAL JOURNAL

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Robert C. Byrd
Health Sciences Center

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Jefferson Memorial,
City Hospital become
affiliated with WVU

Berkeley and Jefferson counties are
now part of a “medical campus” for
WVU students, thanks to an agreement
signed June 17 at the VA Medical Center.

“Our students who train here will
learn from physicians in these counties,
and will contribute to medical care for
eveiyone in the region,” says Dr. Robert
D’Alessandri, vice president for health
sciences and dean of medicine. “We
are proud to add City Hospital and
Jefferson Memorial Hospital to our
network of educational affiliates.”

The VA Medical Center and the
Shenandoah Community Health Center
are already WVU affiliates, Dr.
D’Alessandri said. The addition of the
two community hospitals gives WVU
students the opportunity to train in a
full range of health care settings, and
the educational agreement is a further
development of the Eastern West
Virginia Health Care Initiative.

Children’s Hospital
doctor receives award

Dr. A. Kim Ritchey,
a cancer specialist at
WVU Children’s
Hospital and WVU
professor of
pediatrics, received
the Robitussin,
Dimetapp and
Wyeth Pediatrics
Miracle Maker
Ritchie Award during a

local segment of the
Children’s Miracle Network telethon.

This award recognizes outstanding
pediatricians and physicians specializing
in children's health care. The award's
sponsors donated $3,000 to WVU
Children’s Hospital in Dr. Ritchey’s name
and presented him with a plaque.

Videoconferences on
stress sponsored by
Behavioral Medicine

The Department of Behavioral
Medicine and Psychiatry is sponsoring a
series of free videoconferences aimed
at giving mental health professionals
the opportunity to share work-related
stress with colleagues throughout the
state.

The videoconferences are being
held the first Tuesday of the month
through December. Topics being
addressed include: the trauma model,
re-enactment, dissociative regression,
hearing voices, body memories and
altered personalities. Each program
airs from 1 1 a.m. until noon via
Mountaineer Doctor Television
(MDTV) at seven sites throughout the
state: Grant Memorial Hospital,
Petersburg; Davis Memorial Hospital,
Elkins; Wetzel County Hospital, New
Martinsville; St. Joseph’s Hospital,
Buchannon; Charleston Area Medical
Center, Charleston; Boone Memorial
Hospital, Madison; and the Robert C.
Byrd HSC, Morgantown.

The videoconferences are being
co-chaired by Dr. Louis W. Tinnin,
professor, and Dr. Lyndra Bills,
assistant professor of behavioral
medicine and psychiatry.

For more information about the
videoconferences, call Dr. Tinnin at
293-2411.

Charleston Division,
CAMC host Visiting
Clinician Program

CAMC is sponsoring a Visiting
Clinician Program in conjunction with
the Charleston Division of the Robert
C. Byrd HSC, in order to expand the
the Morgantown Visiting Clinician
Program and to give participants the
opportunity to work with physicians
from both the Morgantown and
Charleston areas.

Dr. Mitch Jacques, chair of the
Department of Family Medicine,
Charleston Division, is the program’s
medical director; and Melissa Long is
the acting program coordinator.

Professor/chair of
pathology chosen as
leadership scholar

Mary Ann Sens,
Ph.D., M.D.,
professor and chair
of pathology, has
been chosen as a
leadership scholar
in Academic
Administration and
Health Policy by
the Association of
Academic Health
Centers (AHC).

This program recognizes senior
level women and minority faculty
members who have the potential to
move into the top leadership ranks of
academic health centers within the
next few years. Scholars remain at the
their home institutions while they
participate for three years in the
activities of the AHC that emphasize
networking and mentoring.

Dr. Sens was nominated for this
scholarship based on her efforts to
minimize the use of animals in
medical research, and for her work as
a forensic pathologist in identifying
acts of violence via pathology.

Beattie appointed to
National Board of
Medical Examiners

Diane S. Beattie,
Ph.D., professor
and chair of
biochemistry, has
been appointed to
the National Board
of Medical
Examiners as a
test committee
representative.

The National
Board of Medical
Examiners is a non-profit organization
that prepares and administers
qualifying exams for medical licensure.
Dr. Beattie is involved in biochemistry
test material development for the MLE.

Sens

302 THE WEST VIRGINIA MEDICAL JOURNAL

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Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

New research facility
at VA Center to benefit
medical education

In addition to enhancing medical
care to veterans, a new research
addition at the Huntington VA Medical
Center will mean improved education
for medical students, according to Dr.
Charles H. McKown Jr., dean of the
Marshall University School of Medicine.

Sen. Robert C. Byrd, Senate Appro-
priations Committee chairman, included
the $9-9 million project in the 1995 VA/
Housing and Urban Development Bill
the committee approved July 14. The
bill now goes for approval to the full
Senate, the House of Representatives
and the president.

Dr. McKown said veterans and
students alike will benefit from the
center’s ability to attract an expanded
range of physicians highly qualified to
treat veterans and serve as medical
school faculty.

“Typically, the very best physicians
want to associate with a medical
school, and usually they want to
conduct laboratory research as well,”
Dr. McKown said. “The quality of our
research has been absolutely
outstanding, but lack of adequate lab
space definitely has restricted the
amount of research done and the
scope of our research program.”

The research building will be built
adjacent to the Coon Medical
Education Building, which houses
classrooms, faculty offices and labs for
the first two years of the medical
school curriculum. The new building
will have 28,660 gross square feet of
space, enough for 10 to 12 modern
research labs and support facilities.

Currently, Marshall/VA doctors are
working on several VA research
projects to prevent or better treat such
widespread health problems as heart
disease, diabetes, and infectious
diseases. The labs for these projects
are located in a old nurses’ dormitory
which is undersized and lacks the
features necessary for conducting a

more advanced medical research
program, the dean said. Furthermore,
the VA labs are at the opposite end
of the medical center compound
from the Medical Education Building.

“The new facility will allow our
researchers to work more closely
together and use resources most
efficiently,” Dr. McKown said.

The Huntington VA Medical Center
had no research facilities when it
became affiliated with the new
Marshall University School of Medicine
in 1977. By 1990, all space in the
nurses’ dorm was in use. Last year's
opening of the Robert C. Byrd Clinical
Addition underscored the need for
improved lab facilities. The pressure for
adequate lab facilities intensified with
last year’s opening of the Robert C.

Byrd clinical addition. That addition,
which doubled the center’s patient care
space, also increased the VA’s need to
recruit additional qualified physicians,
including some in new specialty areas.

Several faculty receive
tenure, promotions

Six Marshall University School of
Medicine faculty received tenure
effective July 1, and 11 received
promotions.

The faculty members who received
tenure and promotions were:

Anatomy, Cell and Neurobiologv

Sasha N. Zill, Ph.D., promoted to
professor;

Family and Community Health

Kathleen M. O’Hanlon, M.D.,
promoted to associate professor;

Medicine

W. Michael Skeens, M.D., promoted
to associate professor;

Kevin W. Yingling, M.D., promoted
to associate professor;

Microbiology, Immunology and
Molecular Genetics

Donald A. Primerano, Ph.D.,
granted tenure and promoted to
associate professor;

Obstetrics and Gynecology

Ted P. Haddox, M.D., promoted to
associate professor;

marshalimJniversity

Pathology

David C. Leppla, M.D., granted
tenure;

Pharmacology

Monica A. Valentovic, Ph.D.,
promoted to professor;

Pediatrics

Yoram Elitsur, M.D., promoted to
professor;

Joseph W. Werthammer, M.D.,
granted tenure and promoted to
professor;

Social Work

Girmay Berhie, Ph.D., granted
tenure and promoted to professor;

Jody Gottlieb, A.C.S.W., promoted
to associate professor;

Surgery

James P. Carey, M.D., granted
tenure; and

William M. Cocke, M.D., granted
tenure.

Rhoten participates in
seminar in Zimbabwe

Dr. William B. Rhoten, chair of the
Department of Anatomy, Cell and
Neurobiology, recently participated in a
faculty development seminar hosted by
the Council on International Educational
Exchange in Harare, Zimbabwe.

The seminar emphasized issues
relating to development in southern
Africa, especially Zimbabwe. The topics
discussed included the University of
Zimbabwe Amendment Act and
academic freedom, gender problems
and AIDS-related diseases.

Alumni weekend set

Reservations are being accepted for
this year's Alumni Homecoming
Weekend, September 30 - October 1
at the Huntington Radisson.

Dr. Pat Brown's faculty/alumni
mixer will be at 8 p.m. on September
30, and the CME meeting will begin
the following morning at 8 a.m.

For details, call 696-7246

304 THE WEST VIRGINIA MEDICAL JOURNAL

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R. Vawter, M. D.

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E. C. Voss, M. D.
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R. V. Pangilinan, M. D.

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Cardiac Ultrasound

Clinical Laboratory

Medical
Student News

Expanding our horizons

Dear Fellow Medical Students:

The WVSMA-MSS has been receiving a great deal of attention recently due to the Medical Student Survey that has
been circulated to all medical students in the state. Two students from the Charleston chapter, Bonnie Bailey and
Henry Higgins, have been compiling the results and they have reported that the surveys contain many valuable
recommendations for improving our health care system. Once the information is tabulated, we plan to publish an
article in the Journal and present the results to the members of the West Virginia Legislature.

Another recent highlight for the WVSMA-MSS was the Annual AMA Medical Student Meeting in Chicago, which
seven of us from the three different campuses were able to attend. We had the pleasure of meeting medical students
from all over America, and to observe how they came together on the assembly floor to accomplish a common stance
on a variety of issues. Nick Cottrell, vice president of the WVSMA-MSS Executive Council, amended MSS
Resolution 31 - First Aid Training For Child Daycare Workers, which was accepted. He also aided in the debate
of the Physician Workforce Planning Strategies issue. In addition, as a result of A-94, we will be able to increase
our contributions at next year’s conference, as well as encourage more WVSMA-MSS members to participate.

In other news, the WVU Charleston Medical Student Society recently elected officers: Jeff Floyd-President,
Christy Brodisch-Vice President, and Michael Cabral-Secretary/Treasurer. We are also in the process of creating a
new component student chapter for students at the West Virginia School of Osteopathic Medicine in Lewisburg,
and encouraging WVSOM students to become involved in the WVSMA-MSS.

The WVSMA-MSS Executive Council is currently writing amendments for our bylaws which would better
define who will serve as delegates and alternate delegates to the national meetings. We also want to improve
the election process for the Executive Council. Any amendment to our bylaws requires an affirmative vote by
two-thirds of the active members in attendance at the Annual Business Meeting. If anyone has any suggestions
for improving our constitution or the section in general, please contact your component society president. In
addition, the WVSMA-MSS has submitted a resolution on graduate medical education to be presented at the
WVSMA House of Delegates' meeting during the WVSMA Annual Meeting at The Greenbrier.

In conclusion, we are currently planning our Annual Business Meeting, which will be held next January in
Huntington in conjunction with the WVSMA Mid-Winter Clinical Conference. The WVSMA-MSS continues to
become a more active and influential organization and I am looking forward to a very productive fall.

David C. Faber, MS III
WVSMA-MSS President

306 THE WEST VIRGINIA MEDICAL JOURNAL

.one

voice for medical education.

The Medical Student

of Today
Will Be

Your Doctor
Tomorrow.

Support the American
Medical Association
Education and
Research Foundation.

Your Contribution
is Tax Deductible.

West Virginia Medical Journal

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UNIVERSITY OF MARYLAND
BALTIMORE

Volume 90 No. 8

West Virginia State Medical Association

FERRELL P H Q T 0 G R A P H I C S

Specializing in public relations and advertising
photography for the health care industry

1116 Smith Street Suite 217 Charleston, WV 25301 Phone:(304)340-4254

EDITOR

, Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

[ MANAGING EDITOR

I Nancy L. Hill, Charleston

i EXECUTIVE DIRECTOR

' George Rider, Charleston

ASSOCIATE EDITORS
John M. Hartman, M.D., Charleston
Joe N. Jarrett, M.D., Oak Hill
Robert J. Marshall, M.D., Huntington
David Z. Morgan. M.D., Morgantown
Louis C. Palmer, M.D., Clarksburg
Harvey D. Reisenweber, M.D., Martinsburg
Mabel M. Stevenson, M.D., Huntington

I RESIDENT EDITOR

Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

West Virginia Medical

CURNAL

Contents

Feature Article

WVSMA staff members highlighted 318

Special Reports

An overview of the AMA Annual Meeting 320

An overview of the AMA-HMSS Annual Meeting 321

Scientific Newsfront

A review of the treatment of intracranial metastases

resulting from malignant melanoma 324

Noise and hearing 327

How healthy are teens in Russia and Estonia? 330

Postmaster send form 3579 to the West
Virginia Medical Journal, 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January' 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

Manuscript Guidelines

President’s Page

Where do old presidents go?

332

334

WEST VIRGINIA MEDICAL IOURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: S36 a year in the U.S.;

| $60 in foreign countries; S3 per single copy.
Address communications to the West
Virginia Medical Journal. P. O. Box -H06,
Charleston, WV 25364.

Due to increasing publication and mailing
I costs, the West Virginia Medical Journal will
not honor claims for back issues for any
reason, unless these claims are received
within a 6-month period after issue of the
publication requested.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Road,
Ann Arbor, MI 48106.

1-800-257-4747 or (304) 925-0342

USPS 676 740
ISSN 0043 - 3284

Editorials

James L. Comerci, M.D 335

Oxymoronic 335

Special Departments

General News 336

1994-95 WVSMA Delegates/Alternates 339

1994-95 WVSMA Annual Meeting Exhibitors 340

Continuing Medical Education 342

Medical Meetings/Poetry Corner 343

Bureau of Public Health News 344

Robert C. Byrd Health Sciences Center of WVLI News 346

Marshall University School of Medicine News 348

Alliance News 350

Classified 353

August Advertisers 354

Front Cover

A black bear enjoys his day at the West Virginia Wildlife
Center in Upshur County. Photo by Stephen Shaluta Jr.,
West Virginia Division of Tourism and Parks.

AUGUST 1994, VOL. 90 317

WVSMA staff members highlighted

George Rider

Executive Director

George functions as general manager of the WVSMA and
oversees all staff functions; prepares and recommends the
annual budget with the aid of the finance manager and
oversees its implementation; recommends programs to the
Executive Committee and Council; coordinates legislative
activities; works with outside legal counsel; interacts with
the Board of Medicine and the various publics; and
supervises building maintenance and operations.

Nancie Diwens

Associate Executive Director

Nancie assumes the responsibilities of the executive director
in his absence and serves as office manager; assists the
Executive Committee and Council in carrying out the policies
in the Constitution and Bylaws; coordinates the WVSMA
Continuing Medical Education Accreditation Program, the
Annual Meeting, the Mid-Winter Clinical Conference, and
Speakers’ Bureau; serves as the WVSMA liaison for Nationwide
Insurance Company-Medicare Operations; develops
non-dues revenue programs; administers travel policies for
educational meetings; and directs two worldwide travel
programs for members.

Michelle Ellison

Public Relations/
Advertising Manager

Michelle coordinates all public
relations functions for the
WVSMA; writes news releases;
designs brochures and promotional
materials; creates the monthly
publication Medical Newsline y
works with the finance manager
to maintain all advertising
accounts for the West Virginia Medical Journal, recruits
new advertising for th e Journal; interacts with the
managing editor to determine advertisement placement;
proofreads advertising copy; serves on the Publication
Committee; updates the subscriber mailing list for the
Journal; and acts as a liaison with county medical
societies in developing mini-internship programs.

Nancy Hill

Managing Editor/

WV Medical Journal
Nancy writes news articles,
edits and proofreads all copy,
designs the layout of the
pages, and takes photographs
for the West Virginia Medical
Journal, the WVSMA’s
monthly magazine; works
with the editor, public
relations/advertising manager and printer on various
production aspects of [he Journal; prepares financial
statements regarding [he Journal if needed; assists
staff members with proofreading and creating news
releases, correspondence, advertisements, brochures
and other publications; and serves on the Publication
Committee.

318 THE WEST VIRGINIA MEDICAL JOURNAL

Shirleen Lipscomb

Executive Secretary >
Shirleen functions as general
assistant to the executive
director, associate executive
director. Executive Committee
and Council; performs clerical
duties, handles routine
information and inquiries related
to the daily operation of the
WVSMA; coordinates the
Physician Protection (Loss Control) Program and CME
accreditation for hospitals and organizations throughout
the state for Category I CME credit; coordinates visits of
the WVSMA president and WVSMA staff members to the
component societies; and assists in the planning and
registration at the Annual Meeting, the Mid-Winter
Clinical Conference and all other seminars and
workshops sponsored by the WVSMA.

Misty Ramsey

Receptionist
Misty answers and directs
incoming calls; coordinates
registration for the Annual
Meeting and the Mid-Winter
Clinical Conference; orders and
keeps inventory of office
supplies; maintains office
equipment and the WVSMA's
computer system; types

correspondence for the West Virginia Medical Journal;
opens and distributes mail; assists with special projects;
and compiles weekly computer backups of all office
files.

Winnie Martin

D i recto r of Government
Relations

Winnie serves as executive
secretary to the WVSMA Alliance
and to WESPAC, the West
Virginia Medical Political Action
Committee; manages
government relations by
researching and analyzing
legislative issues, lobbying the
Legislature, monitoring interim committee meetings, and
assisting with the WVSMA Legislative Committee; serves
as liaison to the Council; writes and edits VCPSGRAM,
WVSMA’s bimonthly publication; Legislative Update , a
weekly newsletter produced while the Legislature is in
session, and MedLink, the WVSMA Alliance’s newsletter.

Sue Shanklin

Finance Manager

Sue manages all WVSMA
finances including the recording
of all assets, liability, fund
balance, accounts receivable,
accounts payable, investments
and employee benefits as
needed; maintains biweekly
payroll and employee leave
records; prepares monthly
general ledger and quarterly tax returns balance sheet,
and profit and loss statement; assists and supplies
financial data to the auditing firm for preparing annual
audit and annual tax returns; prepares annual operating
budget and financial statements for the treasurer,
Executive Committee and Council; and serves on the
Finance Committee.

\ ' r v

w 5

Becky Peterson

Project Coordinator
Becky coordinates the program
planning and development for
the Annual Meeting and the
Mid-Winter Clinical Conference;
compiles appropriate data for
applications and approval of
continuing medical education
hours; coordinates and assists
support for the new programs
and other projects for the membership; provides clerical
support for the Annual Meeting Program and Mid-Winter
Program committees and the Medical Education
Committee; and assists the Executive Director, Associate
Executive Director and the Executive Secretary as
needed.

Donna Webb

Mem bersh ip Coordinator
Donna keeps dues and
informational records on all
active, retired and student
members; acts as WVSMA’s
liaison with AMA for
membership activities; compiles
and creates roster for members;
recruits new members; interacts
with county societies on
membership matters; assists with special projects; serves
as exhibit manager for the Annual Meeting and the Mid-
Winter Clinical Conference; and updates mailing lists
and prepares labels as requested by staff members and
other organizations.

AUGUST 1994, VOL. 90 319

An overview of the AMA Annual Meeting

Members of the WVSMA’s delegation at the AMA Annual Meeting included: (Front Row) Senior Councilor at Large Dr.
Constantino Amores; Associate Executive Director Nancie Diwens; and President-Elect Dr. Denny Burton. (Second
Row) Executive Director George Rider; Dr. Stephen Thilen; Dr. Robert Hess; Junior Councilor at Large Dr. James
Bryant; and Council Chairman Dr. Robert Pulliam. (Back Row) Dr. David Avery; Vice President Dr. James Helsley;
and President Dr. James Comerci. Not pictured is Dr. John Holloway.

The AMA’s Annual Meeting took place in Chicago from June 12-16. Members of the WVSMA’s delegation took an active
roll with many of the reference committees, and I was fortunate to be able to serve on Committee H, which focused on
health care data systems.

The House of Delegates debated 212 resolutions and 106 reports during the course of the meeting. A discussion on
health care reform drew the largest attendance I have ever seen at an AMA Annual Meeting. As a result of this hearing, the
AMA developed a policy to achieve universal access and coverage through an approach that would utilize employee and
individual responsibilities. This new plan would maintain individuals’ rights to chose their own their own physicians and
insurance plans.

In other actions at the meeting, there was a strong effort to encourage the development of health savings accounts, and
to support the health care reform plan that contains these interests. A reference committee also reaffirmed the policy AMA
has for preserving and expanding physicians’ rights to develop their own fee schedules and not have them restricted by
outside forces.

The continuing problem of defining primary care was also debated at the meeting. As a result of these discussions,
strategies were developed to help modify physician distribution by individual and local needs, not by arbitrary percent
distribution. Plans were set into motion to create a National Health Work Force Advisory Council and Graduate Medical
Education Commission.

The delegates focused much attention on the issue of childhood abuse and violence in America. Policy statements were
established to recognize the fact that adult memories of childhood sexual abuse cannot always be proved, so this subject
will be monitored by the AMA. In addition, the AMA continues to work with the AMA Alliance to prevent family violence
and increase awareness of this problem.

Of all the subjects discussed at the meeting, though, the major topic was managed care. The House of Delegates developed
policies to permit physicians to negotiate individually and collectively, and to provide formal input of physicians into the
policies of the managed care organizations they are, or would be participating in.

A detailed summary of the actions taken by the AMA House of Delegates is available at the WVSMA office in Charleston.
I hope that more WVSMA members will express their ideas and opinions to the members of our delegation so we can
better represent you at future meetings.

;

i c

1 r

David W. Avery, M.D.
AMA Delegate

320 THE WEST VIRGINIA MEDICAL JOURNAL

Special Report

An overview of the AMA-HMSS Annual Meeting

The Twenty-third Annual AMA Hospital Medical Staff Section (AMA-HMSS) Assembly was held June 9-13 in Chicago. The
meeting was attended by 412 representatives, 23 alternate representatives, 81 observers, and 13 guests, whose contributions
lead to a very productive, informative and educational session.

On the first night of the assembly, representatives had an opportunity to have a dialogue with three members of the AMA
Board of Trustees. Board members fielded over 30 questions on topics that ranged from concerns about the Joint
Commission’s “Agenda for Change” to AMA’s views on various aspects of health system reform. Through direct
communication with AMA leadership, HMSS representatives were able to gain greater clarity on AMA policy and positions
relative to medical practice issues.

In his opening address, AMA-HMSS Governing Council Chair Lee H. McCormick, M.I)., spoke candidly about the
evolution in health care and its implications for physicians, as well as the need for a restructuring of organized medicine to
accommodate physicians now practicing in managed care networks. He also underscored the need for physician
involvement to ensure positive health system reform changes.

In concert with Dr. McCormick’s message, an educational program was conducted which focused on physician
involvement in health system reform and offered strategies for dealing with change. The program was lead by Nellie
O’Gara, a Chicago health care consultant, who warned physicians of the massive restructuring to form horizontally and
vertically integrated systems, the rapid consolidation of managed care plans, and the imminent battle for control of
premium dollars.

The next speaker, David Main, a health care lawyer from Washington, D.C., concurred with Ms. O’Gara and added that
physicians are best positioned to take control because of their knowledge of managing care and costs. He also stated that
physician-directed plans can provide patients with better value than other structures.

AMA’s Associate General Counsel Edward Hirshfield then reviewed AMA’s two legislative proposals: the Physician Health
Plans and Networks Act of 1994, which would offer tax breaks and incentives for formation of physician-owned plans; and
the Patient Protection Act, which would provide protection to physicians regardless of the plan’s ownership and require
plans to give patients and physicians information on coverage limits and contracting. In addition, he also announced AMA’s
Capital Pool Project, which seeks to bring physicians needing capital together with business planners, bankers, and other
investors; and he explained AMA’s push for antitrust relief to help facilitate physician networking.

Noah Rosenberg, a California-based health care lawyer, closed this session with a presentation on capturing the
institutional revenue stream. He advised that a physician organization’s assumption of institutional risk does not guarantee
additional revenue to physicians, but requires them to work hard to manage medical care efficiently, while ensuring quality.
He added that physician organizations must recognize the importance of the institutional dollar, and network together to
retain the necessary' medical management, as well as the financial and legal expertise for achieving success.

The AMA-HMSS Assembly adopted 18 Governing Council reports and 27 resolutions, nine of which were sent over to the
AMA House of Delegates (HOD ). Debate surfaced, both in the HMSS Assembly and HOD, over the Joint Commission’s
development of disclosure policies and hospital numerical report cards. The result was a new policy, which directs the
AMA to ask the Joint Commission to oppose the release of Organization-Specific Compliance Information to the general
public until the AMA-HOD has the opportunity to assess how the data are gathered, analyzed, validated and distributed.

The policy also requests AMA representatives to the JCAHO Hospital Accreditation Program/Professional and Technical
Advisory Committee (HAP/PTAC) to be appropriately involved in the development of disclosure policies and hospital
numerical report cards. The Board of Trustees was charged with continuing its efforts to advocate AMA policy to the
JCAHO with a plan for JCAHO accreditation of provider networks, public disclosure to standards compliance information,
and the revision of the medical staff chapter.

Concerns also were raised about the use of proprietary practice parameters in utilization management. The AMA-HMSS
alerted the HOD about the lack of involvement of national, state, and medical speciality societies in creating these
guidelines and the possibility' that such day-to-day protocols may become necessary constitute the practice of medicine. The
HMSS was successful in obtaining support for AMA activities for ensuring that practice parameters are developed in
compliance with AMA principles and the involvement of relevant physician organizations.

At this meeting, the AMA-HMSS also succeeded in gaining support for efforts to:

(1) Enhance fairness to patients and providers under managed care health benefit plans;

(2) Encourage those physicians who are entering into managed care organizations to do so by forming or participating
in physician-owned or directed organizations;

(3) Implement the Capital Pool Project and include the AMA University Project, which provides training for physicians
on the economics of managed care, marketing and position practice, administrative systems, and income prospects;
and

(4) Sponsor the Physician Health Plans and Networks Act of 1994.

Norman W. Taylor, M.D.
Chairman of the WVSMA-HMSS

AUGUST 1994, VOL. 90 321

Representation

Education

and

Networking

Federation

Consortium

Study

Hospital Medical Staff Section
24th Assembly Meeting
December 1-5, 1994
Sheraton Waikiki Hotel
Honolulu, Hawaii

Send a representative from your hospital medical staff and physician organization to the
1994 Interim American Medical Association Hospital Medical Staff (AMA-HMSS) Assembly Meeting
held on December 1-5 in Honolulu. Aside from participating in the development of AMA policy,
representatives will have an opportunity to network with colleagues, dialogue with the AMA Board
of Trustees, and hear the latest news and information on health system reform.

With a changing health care environment, broader diversity within the physician population, limited
resources, and an overriding need for unity of purpose and action by organized medicine, the AMA
has undertaken a study of the Federation.

The study, involving county, state and specialty societies, the AMA, and other related organizations,
intends to uncover useful information for developing ways to increase membership, member
participation, and advocacy as well as improve communications, medical society performance, and
resource utilization.

Project leaders have asked the AMA-HMSS to participate in the process because it effectively
represents grassroot physician concerns. Input from each HMSS representative also will be extremely
valuable in defining organized medicine in the future.

The 1994 Interim AMA-HMSS Assembly Meeting Education Program will host the Consortium study.
Data collected and analyzed will facilitate the following objectives:

• Identify current and future needs, expectations, and preference of physicians and others for
organized medicine;

• Explore membership ideas and options;

• Assess how medical societies relate to each other — including ways to be more supportive, avoid
duplication of effort, leverage strengths, and better address weaknesses;

• Discover whether there are better tools/technologies that medical societies can use to communicate
with one another and their members; and

• Enable medical societies to work smart in a more focused and purposeful way.

Plan to participate in the Federation Consortium on Friday, December 3 from 2:30 to 5:30 pm in
Honolulu, Hawaii. Mahalo!

American Medical Association

Physicians dedicated to the health of America

\ West Virginia university school Of medicine

WkM Office of Continuing Medical Education

20th Annual Hal Wanger Family Medicine Conference

September 15-17, 1994

Robert C. Byrd Health Sciences Center of West Virginia University
Morgantown, WV

Registration Form

Registration is recommended by September 1 , 1994.

Name Degree

Home Address

(MD, PhD, etc.)

City

State

Zip

County

Work Address

City

State

Zip

County

Day-time Telephone ( ) Home Telephone ( )

Social Security Number - - Affiliation

Specialty Subspecialty

Please specify the exact name to be printed on your certificate. Print or type name.

Course Fees*

Price

Total

Full conference

$195.00

Thursday and Friday

$165.00

Friday and Saturday

$150.00

Thursday only

$100.00

Friday only

$100.00

Saturday only

$ 90.00

Suturing Techniques Laboratory

$ 50.00

Football Tickets (limit 4) WVU vs. Maryland x

$ 20.00

*Course fees include conference materials, credit, and meals. Total

Credit Card payment: Please charge my DVisa □ MasterCard Card number

Expiration date Authorization signature

Fax registration and credit card payment to (304) 293-4891 or mail form with payment to:

WVU Foundation

c/o Office of Continuing Medical Education
1250 Health Sciences South
PO Box 9080

Morgantown, WV 26506-9080

Special Requirements

If you require access and parking for the handicapped, please so indicate:

For more information, please contact the WVU School of Medicine Office of CME at 1-800-WVA-MARS or (304) 293-3937.

The West Virginia University School of Medicine is entitled by the Accreditation Council for Continuing Medical Education (ACCME) to award credits in
continuing medical education for physicians. The Office of CME certifies that this continuing medical education activity meets criteria for 16.5 credit hours in
Category 1 of the Physicians Recognition Award of the American Medical Association.

A review of the treatment of intracranial
metastases resulting from malignant melanoma

STEVEN J. JUBELIRER, M.D.

Director, Cancer Care Center of Southern
West Virginia, Charleston Area Medical
Center ;• and Clinical Professor of Medicine,
West Virginia University, Charleston Division

MARK JONES, M.D.

Dermatology Resident, Medical College of
Pennsylvania

Abstract

Malignant melanoma (MM) is often
reported as the third most common
cause of intracranial metastases
after carcinoma of the breast and
lung. A retrospective review of 49
patients with brain metastases from
melanoma treated at CAMC between
1976 and 1991 was undertaken.
Various factors ( including age, sex,
site and depth of primary lesion, sites
of systemic disease, treatment
modalities, and survival data) were
analyzed. Of the 25 males and 24
females in our study, all but three
patients had primary lesions greater
than 1.5 mm. in depth. At least 80% of
these patients had primary lesions of
the trunk, head/neck, or upper
extremity. The median interval
between the initial diagnosis and
development of brain metastases was
19 months. Complete surgical
resection followed by radiotherapy
resulted in the longest median
survival of 8.3 months; and median
survival for the entire group was
3.2 months. The outcomes of this
study show that complete surgical
resection with adjunctive use of whole
brain radiation, should be attempted
whenever possible, especially in
patients with solitary’ lesions.

Introduction

Malignant melanoma is the third most
common cause of central nervous
system (CNS) metastases, preceded in
incidence only by carcinoma of the
breast and lung (1). Between 6% and
46% of patients with melanoma
develop CNS metastases, often the
precipitating terminal event (1). In

addition, approximately one-third of
all patients with melanoma die
because of CNS involvement, regardless
of the treatment strategies employed (2).

In order to define the clinical picture
and efficacy of therapy for these
patients, we studied the cases of all the
individuals with this diagnosis who
were treated at CAMC from 1976-91.

Methods

We reviewed the tumor registry and
hospital records of all patients treated
at CAMC from 1976-91 who had both
a histological diagnosis of melanoma
and a metastatic brain tumor, which
was confirmed by CT scan, MRI, or
radionuclide brain scan. Patients with
meningeal seeding of tumor but who
did not have intraparenchymal brain
metastases were excluded.

We sought information regarding
age, sex, site and depth of the primary
lesion, extent and sites of systemic
disease, number of brain metastases,
interval from initial diagnosis to brain
metastasis, modalities of treatment, and
survival. Survival was measured from
the time of diagnosis of the brain
metastases.

Patient characteristics

Of the 320 patients with malignant
melanoma seen at CAMC during this
time period, 49 were found to have
brain metastases. There were 23 males
and 24 females, ranging in age from 21
to 85 years, with a median age of 56
years (Table 1). All patients were
Caucasian.

The initial primary lesion was
located on the thorax or abdomen in

Table 1. Age Distribution at Primary
Diagnosis

Aee (Years!

Number of Patients

21 - 30

31 - 39

40 - 49

50-59

60 - 69

70 - 79

> 80

19 patients, on the head or neck in 10,
on the upper extremity in 10, in the
viscera in three, on the lower extremity
in one, and was unknown in sLx of the
patients (Table 2). For some of the
patients, the depth of the primary lesion
was noted (Breslow’s classification
ranged from 0.6 mm. to 7.6 mm. with
a median of 2.8 mm.). The interval
between the diagnosis of the primary
lesion and subsequent intracranial
metastases ranged from one to 122
months, with a median of 19 months
( 1 1 months for males; 23 months for
females).

Symptoms and signs of cerebral
metastases varied depending on the
location and the extent of the
metastases. Confusion or disorientation,
headaches, focal deficits, and seizures
were the most common clinical
manifestations encountered in these
patients (Table 3).

At the time of diagnosis of brain
metastases, 78% of these patients had
recurrent or metastatic melanoma
elsewhere (Table 4). Lung metastases
were found in 16 patients, subcutaneous
metastases in 16, liver metastases in sLx,
bone metastases in five, breast lesions
in one, and adrenal metastases in one.

Methods of diagnosis

Brain metastases were diagnosed by
CT scan in 36 patients (73%), by MRI
in three (6%), by radionuclide brain
scan in two (4%)), by biopsy in four
(8%), by angiography in one (2%), and
by autopsy in one (Table 5). Thirty-five
patients (71%) had multiple brain
metastases and 14 had a solitary
metastatic lesion.

Table 2. Site of Primary Lesion

Site

Number of Patients

Thorax/abdomen

Head and neck

Upper extremity

Visceral

Lower extremity

Unknown

324 THE WEST VIRGINIA MEDICAL JOURNAL

Table 3. Clinical Manifestations of Brain Metastases in Patients with Melanoma at Initial

Presentation

Siens/Svmntoms*

Number

Confusion, Disorientation and Mental Deficit

Headache

Focal Deficit

Motor Deficit

Cranial Nerve Paralysis

Sensory Deficit

Ataxia/Gait Disturbance

Seizure

* Many patients presented with more than one

manifestation

Table 4. Sites of Extracranial Metastases*

Table 5. Method of Diagnosis

Site Number

Method

Number

Lung 16

CT-Scan

Subcutaneous 16

Biopsy

Liver 6

MRI

Bone 5

Brain Scan

Adrenal 1

Angiography

Breast 1

Autopsy

* Patients with multiple metastases were

noted in each category where lesions occurred.

Table 6. Clinical Courses of Patients with Solitary vs. Multiple Metastatic Lesions

Solitary Lesion

Multiple Lesions

Number of Patients

Median Survival (months)

8.3

3.2

% with Liver or Lung Metastasis

Symptomatic Improvement after Treatment

Therapy

Forty-eight patients received whole
brain radiotherapy, 38 of whom
received concomitant corticosteroids.
Twenty-seven patients were treated
with chemotherapy and six received
immunotherapy (interferon-alpha in
five and BCG in one).

Six (42%) of the 14 patients with a
solitary metastasis underwent
craniotomy prior to radiation. All 14
patients received a mean total dose of
3,980 cGy of whole brain radiation
(WBRT) in 10 fractions, 440 of which
were coned down to the primary lesion.
Of the three patients who had follow-up
CT scans, two showed improvement.

The 35 patients who had multiple
metastatic lesions received a mean of
3,509 cGy in 10 fractions. One of these
patients underwent a craniotomy prior
to WBRT. Of the five patients in this
group wrho had follow-up CT scans,
only one showed improvement.

Twenty-two patients (45%) reported
subjective improvement after treatment
was completed (eight with a solitary
lesion) (57%), and 14 (40%) with
multiple lesions). Ten patients
reported no change in neurologic
function, four reported worsening
function, and no information was
available concerning 13 of the patients.

Survival rates

The median survival of the patients
with a solitary metastatic lesion was
8.3 months (range 24 days - 12.5 years),
compared to 3-2 months (range 0 - 2.2
years) in those with multiple metastatic
lesions (Table 6).

In the group with a solitary metastatic
lesion, the median survival of those
undergoing craniotomy followed by
radiotherapy was 8.3 months, while
the survival rate for those receiving
radiotherapy alone was 5.8 months.
The overall one-year survival rate was
14.2%; and the one-year survival rate
of those with a solitary lesion and
those with multiple lesions was 35%
and 7.6% respectively.

The cause of death was determined
in 33 patients. Eighteen patients (54%)
died of recurrent intracranial metastases,
1 1 patients (33%) of cardiopulmonary
arrest, one patient of hypovolemic
shock, and one patient of septicemia.
Only two patients are alive; one 14
months and one 36 months after the
diagnosis of brain metastases. No
correlation could be found between
the time interval from initial diagnosis
to brain metastasis, and from brain
metastasis to death (linear correlation
co-efficient = 0.04). The one patient

who is alive and well more than 36
months after brain metastasis had an
18-month interval between initial
diagnosis and brain metastasis.

Discussion

Several diagnostic features were
noted to be associated with a much
higher evidence of brain metastases.

Patients with more invasive primary
lesions as reflected by deeper
Breslow's levels, and patients with
primary lesions of the head and neck,
trunk, or upper extremity, all had a
greater risk of developing CNS
metastases. All but three patients in
our series had primary lesions greater
than 1.5 mm. in depth, and in at least
80% of the histories we studied,
patients had primary lesions of the
trunk, head and neck, or upper
extremity. Each of these features has
been reported previously to be
associated with a poor general
prognosis, which may well be due to
this increased incidence of CNS
metastases (3,4,5,6,7,8,91. In the case

of the deeper Breslow’s (or Clark’s)
level, the incidence of metastases
seems to be related to the greater
likelihood of a general dissemination
of the disease, a conclusion supported
by the higher frequency of positive
regional lymph nodes with deeper
lesions (8).

Survival of patients with brain
metastases from melanoma has been
uniformly poor. The median overall
survival rate of 3.2 months in our
series is similar to that found by Allan
and colleagues (10) in their review of
greater than 750 patients with brain
metastases. Sampson et al (11) reviewed
6,953 melanoma patients, and for the
702 who had CNS disease - the median
survival time was three months. As
noted in Table 7, there are very few
long-term survivors despite the
multiple modalities of treatment used.

Surgical resection offers patients the
greatest chance for survival and
clinical improvement, particularly in
patients with solitary lesions. The
median survival of our patients with

AUGUST 1994, VOL. 90 325

single lesions treated with surgery and
radiotherapy was 8.3 months, compared
to 5.6 months in those treated with
radiotherapy alone.

Numerous retrospective studies
have indicated a greater median survival
in those individuals with surgery ±
whole brain radiotherapy (WBRT)
compared to radiation alone (26). A
recent prospective randomized trial was
performed in which 48 patients with
known systemic cancer ( some of whom
had melanoma) were treated with either
biopsy of the suspected brain metastasis
plus WBRT or complete surgical
resection of the metastasis plus WBRT.
The radiation doses were the same in
both groups and consisted of a total
dose of 3,600 cGy given as 12 daily
fractions of 300 cGy each. There was a
statistically significant increase in survival
in the surgical group (40 weeks vs. 15
weeks). In addition, the length of time
until the brain metastases reoccurred
and the duration of functional
independence were significantly
longer in the resection group.

Evaluating the clinical response of
metastatic brain tumors to radiation
surgery or chemotherapy is difficult.
The failure of other organ systems may
mimic progressive neurologic disease
even when treatment has been effective.
Furthermore, the marked salutary effect
of corticosteroids on brain tumors makes
it difficult to measure the clinical
response to other modalities of therapy
while steroids are being administered.
Thus, the change in CT or MRI scan
after therapy is an important indication
of response. However, few patients in
other studies (14,17,19,25) or in our
own series had follow-up CT scans.

Stereotactic radiosurgery is an
attractive therapeutic strategy less
invasive than other modalities that
provides high-dose, single-session
irradiation to a localized tumor volume.
Recent reports indicate that radiosurgery
is being used in an increasing number
of patients with metastatic cancer,
particularly in those with tumors less
than 3 cm. in diameter (28,29,30). A
randomized prospective trial is
underway in several institutions that
are evaluating the use of radiosurgery
for multiple metastases (two to four
tumors) including melanoma. Patients
are randomized to receive either
fractionated WBRT (30 Gy) plus
radiosurgery or WBRT alone. A
separate randomized trial comparing
WBRT (30 Gy) plus radiosurgery to
radiosurgery alone in patients with
newly-diagnosed solitary CNS lesions
is also ongoing (30).

Table 7. Survival Data of Patients with Brain Metastases from Malignant Melanoma:
Comparison of CAMC and Published Series

Primary to CNS Median Survival > 1 yr. > 2 yr.

Investigator

# of Pts.

Metastasis Cvr.l

(Monthsl

Survival (%)

Survival (°/o)

Saha et al 9

117

3.5

4.7

Amer et al 12

3.9

10.7

< 3

Choi et al 13

194

2.5

12.4

2.5

Retsas et al 14

100

2.5

Madajewiez et al 15

125

2.25

< 5

< 2

Stevens et al 16

129

3.5

7.7

Byrne et al 17

2.5

1.2

Beresford et al 18

2.6

2.7

Gottleib et al 19

2.9

2.4

Hilaris et al 20

3.7

Carella et al 21

3.3

< 1

Straus et al 22

Atkinson et al 23

113

0.9

Vlock et al 24

4.3

Stewart et al 25

2.5

5.5

Present Study

1.6

3.2

14.2

References

1. Balch CM, Houghton AN. Diagnosis of
metastatic melanoma at distant sites. In:
Balch CM, Houghton AN, Milton GW, et al,
editors. Cutaneous melanoma. Philadelphia:
IB Lippincott, 1992:439-67.

2. Budman DR, Camacho E, Wittes RE. The
current causes of death in patients with
malignant melanoma. Eur J Cancer 1978;
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326 THE WEST VIRGINIA MEDICAL JOURNAL

Noise and hearing

JOSEPH B. TOUMA, M.D., F.A.C.S.

Clinical Professor, Marshall University School
of Medicine, Huntington: and Associate
Clinical Professor, ENT Department, West
Virginia University School of Medicine,
Morgantown

Abstract

This article addresses the various
types of hazardous noise, their
effects on hearing, and the factors
which contribute to noise-induced
hearing loss. The means of
protecting hearing, both by reducing
the emission of noise and the use of
personal protection , are also
discussed in detail

Introduction

Noise pollution is a widespread
phenomenon. Except in some remote
rural areas and in primitive,
underdeveloped countries, exposure
to sometimes hazardous noise cannot
be avoided, especially in industrialized
countries.

Retrospective and prospective
studies have concluded that noise up
to the level of 85 decibels is not
hazardous and will not affect the
hearing. Noise above this level,
though, will cause damage to hearing;
and the louder the noise and the
longer the exposure, the more
damage that will occur to the hair cells
(1,2,3). OSHA published guidelines of
the permissible length of noise
exposure to various levels of noise
using the TWA (4) (time-weighted
average) (Table 1). Hearing conservation
measures are required anytime the
intensity and duration of noise exceeds
the safe level or when workers exhibit
permanent threshold shift.

Effects on the cochlea

Hazardous noise can cause vascular
changes of the cochlea, causing
metabolic and electrolyte disturbances
which lead to progressive deterioration
of the outer hair cells first and then
the inner hair cells. Gunfire and other
explosive noises will cause direct
mechanical damage to the hair cells
(5,67,8).

After initial exposure to a hazardous
noise, the individual will experience a
temporary threshold shift followed by
some recovery, but in most instances,

the recovery is not complete. Pennanent
threshold shift is the result of exposure
to damaging levels of noise.

Hearing loss results from long-term
exposure to hazardous noise and the
cumulative effect of noise on the hair
cells. The first frequency to be
affected is the 4,000-hertz frequency
with its typical notch (9,10) (Figure 1).
However, after continuous exposure,
the higher frequencies will follow suit,
and then the mid-frequencies. The
last, and the least, to be affected are
the low frequencies. After years of
noise exposure, an audiogram will
have the “ski slope" pattern (Figure 2).

Non-industrial exposure

Noise exposure can be divided into
two categories: non-industrial and
industrial.

This first type includes some common
environmental noises (Table 2) and
the following sources can generate
hazardous levels:

1. Shooting that results from hunting,
target shooting, basic military
training, and home defense can
generate sound that can reach
140-150 dBA SPL level which can
directly destroy the hair cells. The
effects of explosive sounds vary,
depending on whether the blast
occurs in a closed or open area,
the distance of the firearm from
the ear, whether the person is
wearing ear protection or not, the
number of rounds, and the length
of exposure. Hearing loss is
generally asymmetrical and is
worse in the ear opposite to the
predominant side due to the way
the weapon is held and the
position of the head.

TABLE 1. Time Weighted Average (TWA)
Developed by OSHA

Hours

Safe Sound

Per Dav

Level (DBA)

8 hours

6 hours

4 hours

3 hours

2 hours

100

90 minutes

102

1 hour

105

30 minutes

110

15 minutes or less

115

2. Motor sport vehicles such as
speed boats, racing cars,
motorcycles, snowmobiles, water
scooters, model cars and airplanes.

3. Hobbies and daily practices that
involve carpentry and craft tools,
lawn mowers, leaf blowers,
blenders, and vacuum cleaners.

4. Music at some rock concerts can
generate noise levels up to
130-140 dBA at 20-40 feet away
from the stage. Exposure to these
levels of noise for two hours to
three hours will cause hearing
damage. In addition, other types
of concerts and loud car stereos
inside closed windows, radio
headsets blasting directly into the
ears, tape recorders, big bands,
discotheques, and concerts can
also be damaging to the hearing.

5. Miscellaneous sources such as
games and events in sports arenas,
toy guns, arcade video games,
whistles and fireworks.

Industrial noise exposure

There are two kinds of hazardous
industrial noises: continuous noise,
such as noise emitted from turbines;
and impact noise, such as banging
metal on metal, which can directly
damage the hair cells. Hazardous
industrial noises predominantly affect
the high frequencies and generally
save the low frequencies.

Noise is the most hazardous when it
occurs in closed spaces with
reverberation, and the industries that
are the most dangerous are the
following:

TABLE 2. Sound Levels of Common

Environmental Noises

Tvpe of Sound

Loudness (DBA )

Whisper

Low Street Noise

Normal Conversation

Heavy Traffic

Truck, Lawn Mower,

90-100

Subway

Airplane

120

Jet Engine

130-135

Gunshot Blast

140-150

AUGUST 1994, VOL. 90 327

Figure 1. 4000 Hz. Notch

750 1,500 3 000 6.000

250 500 1,000 2,000 4,000 8.000

100

110

r \

\ 7

1. Underground mining.

2. Oil-drilling.

3. Lumber and wood.

4. Paper.

5. Primary and fabricated metals.

6. Food.

7. Textile.

8. Rubber.

9. Plastic.

10. Utilities.

Hearing loss from industrial noise
exposure is usually progressive and
symmetrical. However, it can be
asymmetrical in truck drivers (11,12),
shingle sawyers ( 13), and some miners.

Contributing factors

Animal studies and human
retrospective studies suggest that there
are some contributing factors to noise-
induced hearing loss. Circulatory
diseases such as arteriosclerotic
changes (14,15,16,17), hypertension
(18,19,20,21,22), vascular changes,
smoking (22,23), and diabetes
(25,26,27,28), will increase the
susceptibility of the cochlea to noise,
leading to more severe hearing loss.
Metabolic diseases such as
hypolipoproteinemia, hyper-
cholesterolemia, and high serum lipids
(29,30,31,32,33,34,35) will increase the
vulnerability of the cochlea to noise
due to vascular changes caused by
these diseases.

Age is another factor known to
effect hearing loss since older ears are
more susceptible to noise than
younger ones, even though the
majority of noise-induced hearing loss
occurs in the first 10 years of noise
exposure. Age also causes presbycusis
(4). NIOSH, OSHA and ISO 1999 have
published charts of the expected
hearing level at each age in males and
females.

Other factors which can aggrevate
noise-induced hearing loss include
some ototoxic and industrial
chemicals (36,37,38).

Hearing conservation

The level of noise emitted from any
source can be controlled by either
reducing the loudness or by using
newer technology and different
manufacturing techniques such as
insulating panels. Newer and quieter
equipment will become more
widespread in the future when
factories upgrade their equipment and
machinery; however, this is a very
expensive process.

Personal protection (44,45,46,47,48),
such as the use of ear muffs and ear
plugs, is more economical and offers

the best hope of preserving hearing.
Several kinds of ear muffs are available
and some can be worn alone or with
hardhats, and some have a microphone
for communication. The protection
given by ear plugs varies, depending
on the type of plug. The best results
can be achieved from the foam-rubber
ear plugs which will achieve Noise
Reduction Rates (NRR) of up to 40
decibels.

The important factor is whether or
not these protective devices are used
properly, and not just set aside and
worn only when the supervisor or the
health/safety inspector appears. This
is apparent in the discrepancy in the
NRR measurements in the laboratory
versus measurements in the
workplace. Many workers resist
wearing the hearing protection
devices since they need hearing acuity

328 THE WEST VIRGINIA MEDICAL JOURNAL

to detect any immediate danger, i.e.,
crackling sounds from an imminent
collapse in a mining shaft.

Newer kinds of electronic ear plugs
are now being developed. They
generate sounds which neutralize and
cancel the incoming waves, allowing
only the safe sound to penetrate the
plugs. In another new type of
protection, hazardous noise activates a
valve eliminating the damaging noise.
More research is underway and is
needed to perfect these various
hearing devices.

Other means of controlling noise
include having baffles in public places
such as gyms, civic centers, etc., to
absorb noise and bring it closer to
safe levels. Behavioral measures can
also protect the hearing, i.e., control
of hypertension, a low-fat diet,
prevention of cardiovascular
arteriosclerotic disease, control of
diabetes, and cessation of smoking
will reduce the susceptibility of the
cochlea to noise.

Summary

Noise-induced hearing loss is
insidious and slowly progressive.
Intensive public education is needed
to inform the public of the danger of
exposure to noise, both industrial and
non-industrial.

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22. Borg E. Noise-induced hearing loss in
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23. Barone JA, Peters JM, Garabrant DH,
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24. Siegelaub AB, Friedman GD, Adour K,
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25. Taylor IG, Irwin J. Some audiological
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26. Gibbin KP, Davis CG. A hearing survey in
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27. Miller JJ, Beck L, Davis A, Jones DE, Thomas
AB. Hearing loss in patients with diabetic
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28. Axelsson A, Fagerberg SE. Auditory function
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30. Lowry LD, Isaacson SR. Study of 100 patients
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31. Booth JB. Hyperlipidemia and deafness: a
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32. Axelsson A, Lindgren F. Is there a
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Paparella MM, Leslie K. Diet-induced
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37. Ryan AF, Bone RC. Non-simultaneous
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AUGUST 1994, VOL. 90 329

How healthy are teens in Russia and Estonia?

KATHALEEN C. PERKINS, M.D.

Assistant Professor, Department of Pediatrics,
Robert C. Byrd Health Sciences Center of WVU,
Morgantown

Abstract

This article is a commentary on
the health of adolescents in St.
Petersburg, Russia, and Tallinn,
Estonia. It includes observations on
general conditions in these tiro
cities, which were made during a
brief visit in October 1993 with a
group of specialists in adolescent
medicine.

Introduction

I had the opportunity to visit St.
Petersburg, Russia, and Tallinn, Estonia,
in October 1993 with seven other
members of the Society of Adolescent
Medicine. Originally, we had been
invited to start our tour in Moscow,
but because of the disturbance in early
October at what is now called “The
Black and White House,” our travels had
been shortened to just these two cities.

Flying into Russia, we saw firsthand
that Russian communities are very
willing to replace all remnants of
Leninism. The old sign “Leningrad” in
the airport terminal has been replaced
by “St. Petersburg.” The change of
names nevertheless is minor compared
to the multiple drastic changes going
on across the country.

Since Perestroika, there is no denying
problems and no attempt to cover the
financial and political chaos. The
Russians, though, accept their situation
with equanimity and good humor.

Our guide laughingly told us, “It costs
as much for a box of spaghetti as 1
pay for one month’s utilities in my
apartment. Isn’t that funny? We have
troubles, oh yes, we have troubles but
things are going to get better.”

Even though our visit was to be a
brief one, we hoped to gain insight
into the country’s health care system
and the welfare of its youth.

Tourism

Tourism is a very important business
for the Russians because so many
people depend on it for a living.

Pushkin, an enormous palace just
outside of St. Petersburg which was
completely devastated during World

War II, has been proudly rebuilt and
is now opened for display. This ornate
structure is filled with multiple kinds
of precious stones, mosaic wood,
masterpieces of art, tables with gold,
fancy china place settings and all the
trappings of affluence. Along the
approach to this impressive building,
hundreds of people who are
unprotected from the snow and cold
try desperately to sell trinkets to the
visitors. When I mistakenly took out a
ten instead of a one dollar bill, a dozen
young people hustled around shouting
and urging me to buy something.

The hotel we stayed in was very
modern. Across from it was a
monument which the Russians erected
in honor of their soldiers and citizens
who so courageously defended
Leningrad against the full weight of
fascism in the World War II. It is an
impressive tower of precious stone
flanked by two rows of heroic statues
representing the people who were
sacrificed. Adjacent to it is an
underground sanctuary and an eternal
flame. In sharp contrast to this lavish
glorification of the past, this area is now
where children beg for coins, young
men aggressively sell trinkets and adult
women make a living by pick-pocketing.

The city, itself, seems flat and drab.
Newer streets are wide, but many of
the downtown streets are veiy narrow
which creates a very difficult situation
for two-way traffic. The buildings are
shabby with paint crumbling.

In the summer, tourists are taken to
summer home of Peter the Great. The
extensive grounds at this palace are
landscaped with shrubbery, fountains
and multiple water displays, but there
are no lavoratory facilities available.

Adolescents

In the several hospitals we visited,
some of the young people who
required acute care were in bed, a few
were in traction, but many of them
were dressed in street clothes and
walking around. They appeared clean
but not well off.

Pasty complexions were consistent
with the diet described by our guide.
When asked if children went hungry,
she said, “Oh no! They can always get
bread and usually potatoes and
cabbage.” All patients were thin; very
few Russians appear obese.

For the most part, the young people
appear placid, but we were taken to

some mental hospitals where we found
many patients extremely depressed.
Teenagers may be admitted voluntarily
to psychiatric hospitals where the care
is free of charge. The average stay for
substance abuse is 30 days - 40 days.
Follow-up care is fragmented.

Children in the orphanage we
visited seemed especially well off. The
director expressed concern about the
children’s health and lives in general.
She seem starved for reading material
and information and stated that
professional people had been denied
access to literature for 40 years.

Adolescents have always had their
lives regulated for them. Before they
are 17 years of age, both boys and girls
receive a judicial document indicating
their career evaluation. (There are nine
volumes of guidelines detailing 400
professions.)

At age 17 and again at 18 years of
age, all males have mandatory military
exams. Only 0.6% are refused the
military service, although exams
revealed that 30% of the youths were
disabled and 50% had limiting physical
conditions. After one and one-half years
of this mandatory service, males return
to the occupation previously decided
for them.

Statistics revealed that 90% of the
teenagers in the country smoke, and
that smoking among females had
increased dramatically during recent
years. The Russians are anxious to pass
a law prohibiting tobacco advertising.
Marijuana is home grown, chemically
hazardous and expensive. Teenagers
are also using tranquilizers. In general,
the drug problem is limited due to the
economic conditions of the people. Just
as Americans do in our own country,
the Russians blame the drug problem
on importation from other countries.

Teenage pregnancy is seen as a
problem and there is little discussion
of promoting abstinence as a solution.
Oral contraception has limited
availability, and the people do not have
Norplant, Depo-provera or any of the
newer contraceptive agents. Suggested
contraception methods we read about
in their literature included using hie
rhythm method, coitus interruptus,’
lactation, masturbation, sterilization
and abortion. The average Russian
woman will have four or five abortions
in her lifetime; some many more.

The government, of course, pays for
the abortion. An adolescent with a

330 THE WEST VIRGINIA MEDICAL JOURNAL

positive pregnancy test is sent to a
women's hospital where she receives
free care. This system provides no
incentive to educate young people for
responsible sexual activity. Until the
last five years, statistics were not
publicized or even gathered. At this
time, gonorrhea and syphilis are
diagnosed and treated, but human
papilloma virus and herpes are
overlooked because treatment is not
really available.

HIV is not yet a major problem. All
young men are checked as they enter
the military service. Since 1987, of the
5 million people examined for HIV,
only 65 were found positive — a rate
of .13/1,000. In 1992, statistics were
given on another half million people
and reports then showed a positivity
rate of .08/1,000. In Russia, restriction
of travel and immigration may indeed
have been helpful in preventing HIV
and AIDS. Nevertheless, the young
people are sexually active with no
effort to use condoms which are
limited in supply.

Government health care

The entrance to the St. Petersburg
health department was through a
courtyard behind the building with
trash piles, rubbish and an old
ambulance with a cat lying in front of
it. After walking through several
hallways, up many flights of stairs and
through a series of rooms, we ended
up in a neat orderly conference room.

The professional discussion, in
sharp contract to the surrounding
ghetto, sparked deep admiration for
the staff and their hard work. The
doctor in charge of teenagers spoke
openly of the mistakes that they had
made and spent a long time with the
group discussing their program and
how they wanted to improve it.

The city of St. Petersburg has a
population of 5 million and it is
divided into six regions, 25 districts,
and six suburbs. The city has 95
hospitals, 37,000 beds and 300
polyclinics. Twenty-six of the 95
hospitals have wards for teenagers.

Everyone must register in a
polyclinic, and these facilities are
usually three stories high with three
departments: inpatient, outpatient and
pediatric. Clinic doctors make house
calls if needed, and all people have
access to the same basic care. This
basic care is limited not by the
number of staff, but by funds for
drugs, small equipment and supplies
such as gloves. Since there is little
mobility, there is no expectation or
demand for choice.

The shortage of paper, which results
in a lack of professional cards, table
paper, napkins, and toilet tissue, did
not seem to limit the papers required
to place an order for medical supplies.
At our meals, we were fortunate to have
tiny triangular napkins. A total of eight
napkins were made from a 10-inch
paper square. Tourists are encouraged
to bring their own toilet tissue.

Access to medical care is no problem.
In January 1993, the free health care
system was replaced by a mandatory
medical insurance program.
Nevertheless, local governments pay
the premiums for children, students,
disabled individuals living on pensions,
and people who are unemployed. Many
organizations are still financed on the
government budget, and, if a private
enterprise is losing money, the
government is forced to pay the
premium.

Access to care, however, does not
assure healthy people, and Russia has
major health problems. For example,
even though immunizations are
reportedly required, whooping cough
was often discussed by physicians and
we saw a patient with tetanus, which
the staff said occurred about twice a
year. One physician stated that 70% of
the babies born in the country were
abnormal because they were born
with conditions such as congenital
anomalies, fetal alcohol syndrome and
encephalopathy. In addition, statistics
on 1,000 teenagers indicated that only
2% were fully healthy; 35% had
chronic disease; 65% were considered
at risk for serious diseases; and 80%
required further medical consultation.

Finance, food and sanitation

What good is access to health care
without the financial and social
structures to provide nutrition, sanitation
and productive lifestyles?

In Russia, the collapsed financial
structure leaves the ruble worthless in
the world market. Since the exchange
rate was 13 rubles to $1 in October
when we visited, private traders
preferred to be paid in U.S. dollars.

The Communist regime ignored
villagers pleas and denied individual
families the right to grow some of their
own food and providing their own
shelter. There apparently are a few
private dachas for the wealthy, but
single family homes are strikingly
absent.

The Russian citizens we talked to
told us that the problem was conflict
between the reformist government
and the conservative (Communist)
parliament which Yeltsin dissolved in

October. The Russian Central Bank
has pursued “loose” monetary policies.
Most powerful companies have
borrowed at negative real interest and
have stockpiled output in anticipation
of higher prices. Prices escalated
monthly as evidenced by the following
rates in August and October 1993:

1. A ride on the metro increased
from 36 kopek to 25 rubles;

2. The average monthly phone bill
rose 2 1/2 rubles to 600 rubles;

3. The cost for a breakfast went
from 13-15 kopeks to 120 rubles.

Milk is imported. Long lines of
people can be seen holding half gallon
containers awaiting a small truck with
a 50-gallon tank which pulls up each
day. A container of milk with fruit
(yogurt) can be purchased for 100
rubles.

Sixty percent of the profits
manufacturers earn is paid out for the
salaries of the workforce. In regards
to bread, the peasants obtain 28% of
the price for wheat; the breadmaker
receives 28%; and the store that sells
the bread gets 28%. Presumably the
government, which still runs the food
supply, takes in the balance.

Grocery stores are poorly stocked.
For less than $1, a person could buy
three tiny oranges or a cabbage, and
canned tomatoes with faded labels.
The meat counter we observed
contained a few small, dark, bony cuts
and a few small, scrawny chickens.
Cigarettes cost 30 rubles/pack.

In the Communist era, everyone had
a job. Since Perestroika, a person works
at as many jobs as he/she can. A good
salary of 60,000 rubles/year converts
to perhaps $6,000/year. Physicians
make much less, about $60-$100 a
month. Some of the prices, when
converted to U.S. dollars seemed
reasonable, but based on the average
Russian salary were totally
unreasonable.

Another problem we discovered in
St. Petersburg was filthy lavatories, even
in the medical facilities. At the same
time, newspapers tell of the difficulty
of avoiding hepatitis among
hospitalized patients. Reportedly 42%
of the hospitals have no hot water, 18%
have no sewage systems, and 12% have
no running water (1).

The crumbling financial and legal
structure opens the dooiway to crime.
Several times our group noted the
warning to watch our pocketbooks.

Tallinn, Estonia

Estonia, a Baltic country occupied
by the Soviets from 1949 to 1989,

AUGUST 1994, VOL. 90 331

regained its independence and is very
different from Russia. Anyone
unaware of this, should ride the
sleeper from St. Petersburg to Tallinn.

Travelers, warned that guards on
the job at 3 a.m. might not be happy,
were advised to be quiet and
cooperative. First, the train stopped
and the heavy-booted Russian guards
marched down the aisle. Then, after a
period of time just long enough for
one to fall back to sleep, the Estonian
guards clambered noisily in, banged
open the compartment door, Hipped
on the overhead lights and stomped
into the compartment room. Three
different times they were in and out
and I began to wonder what they were
looking for or at -- especially since my
roommate in the upper bunk just
happened to be an attractive female.

Tallinn, Estonia, compared with St.
Petersburg, was neat and clean.
Repaired sidewalks and roadways,
tidy and freshly painted buildings
gave the city an aura of progress. We
were surprised to see someone
sweeping the gutter — a practice seen
in Russia a decade ago, but not
recently. The stores seemed stocked
and prosperous. There were fresh
fruits and vegetables available in
Estonia that were not offered in
Russia, but they were priced very high
according to our guide.

The hospitals in Estonia were more
modern, and they were doing cardiac
bypass and other high-tech procedures.
Estonians have just legislated a 13%

tax on all employers’ payrolls to be
paid into the fund for “sick care.”
Families will have the choice of which
polyclinic they wish to join. The
Estonians, dealing with the health care
system established during the Soviet
occupation, are improving it and
making it work.

During the 40-year occupation of
Estonia by the Russians, many citizens
were sent to Siberia, but these people
maintained a strong loyalty to their
country and culture. They are proud
and energetic and have great pride in
their culture, tradition and monetary
system. In fact, their monetary system
maintains a relative value with other
world economies, and krones must be
used instead of American dollars.

The Estonians value nutrition and
sanitation. They have a system of health
care with universal access; employers
pay and the government supports. In
Estonia, laws are enforced and limits
on young people are determined.

Estonia is a small country of 1.5
million people that is approximately
the same as that of West Virginia. If
one small country can promote
prosperity and good health, perhaps
one small state should look to do the
same for its population.

Conclusion

The health care system in Russia,
even though it offers universal access,
is not effective in promoting a healthy
population. The financial and political
infrastructures of the country have

failed to provide basic nutrition and
sanitation realities, so choice has been
unimportant since it has not improved
quality.

While it seems essential to retain
one's heritage by restoring buildings,
museums and statues — the lavish
displays and money to restore
buildings and the trappings of the
aristocracy seem out of touch with the
masses of hungry, freezing, poor
people on the street and in the kiosks.
Indeed, the money made by tourist
attractions does not appear to return
to the people.

The Russians are brave and stoic.
They have survived hardship and
seem to accept their lot in life with
surprising equanimity and good
humor. Repeatedly, we heard that the
medical professionals were not
making good salaries, but they liked
what they were doing.

Will the stoic good humor of the
Russian people persist and will they
accomplish change? Will the young
people, accustomed to leadership and
lives planned for them, be capable of
decision making? Are these youth
more mature in resisting drugs,
alcohol and responsible sexual
activity? The Estonian rabbit shows
the way; can the Russian bear do as
well?

References

1. Feshback M, Friendly A. Ecocide in the
USSR: health and nature under siege. New
York NY: Basic Books, 199

Manuscript Guidelines

All scientific manuscripts should be submitted on an IBM
compatible disc in Wordperfect 5.1 or in ASCII (generic). They
must be prepared in accordance with “ Uniform Requirements
for Manuscripts Submitted to Biomedical Journals. ”

All manuscripts should include:

1. Title page

2. An abstract of no more than 150 words
3- Text

4. Acknowledgements

5. References in parentheses numbered consecutively. No
more than 25 references will be published free of charge.

6. Tables

7. Legends for illustrations

All persons designated as authors should qualify for

authorship. Each author should have participated sufficiently
in the work to take public responsibility for the concept.

Where reference is made to generically-designated drugs,
the first such reference must be followed by parentheses
containing its most commonly known trade name.

All scientific material is reviewed by the Publication
Committee and should be sent to The Editor, West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.

332 THE WEST VIRGINIA MEDICAL JOURNAL

SUCCESSFUL

MONEY

MANAGEMENT

We are pleased to announce the 1994 Successful Money Management Seminar schedule. In three exciting sessions,
the workshop introduces you to key concepts and practices of wise money management. You'll learn how to minimize
your taxes, maximize your investment returns, and provide a secure future for yourself and your family.

Another Member Benefit From Your Association !

Areas of Discussion!

• 1993 Tax Law Overview

- Summary of the new Tax Law

- New Opportunities in tax planning

• Estate Planning

- The probate process

- Wills, Trusts, Estate Taxes

• Equity/Fixed Income Investments

- Stocks, Bonds, Ltd Partnerships

- Purchasing strategies. Asset allocation

• Retirement Planning

- Qualified Pensions (SEP’s, 401 K, 403B)

- Select Benefit Plans

Registration Fee $250.00
Spouse Fee $125.00

Spouse’s fee waived if registered 10 days before start of seminar.

If you would like to have a special seminar done in your area, notify
the Medical Association. We will be happy to accommodate you.

Seminars Consist of Three Sessions
6:00 PM - 9:30 PM

Lite Meal Sewed

Clarksburg Area

Wednesdays

September 14th, 21st & 28th

Beckley Area

Wednesdays

October 12th, 19th & 26th

Charleston Area

Wednesdays

November 2nd, 9th & 16th

Fayette County

Thursdays

December 1st, 8th & 15th

^ Clarksburg Area

September 1994

□ Beckley Area

October 1994

□ Charleston Area

November 1994

—I Fayette County

December 1994

Reserve Your Place!

Don’t Wait!!!

Remember, spousal fee is waived if reservations are confirmed 10 days prior to the seminar date
Return this self-addressed card, or call the WVSMA at (304) 925-0342.

Please Call Today!!!

Name

Spouse’s Name If Attending

Address

City State Zip

Phone Office

Traditionally, the President’s Page
for the August Journal should recap
the past year and highlight any
successes or shortcomings (if any).
While at times this year has seemed to
go on forever, it truly has been very
short — just barely enough time for
me to get my feet wet and begin
tackling the many goals I hoped to
accomplish.

1 feel the details of the past year
have been reported in the Journal
and the WESGRAM, therefore, I would
like to reflect on only a few areas of
importance during the last year:

— We now have a full staff at the
office. Good morale, efficiency
and excellent working relationships
are evident.

— We have continued to maintain a
strong legislative presence in
Charleston, as well as around the
state.

— Our CME accreditation activities
have increased and continue to
grow.

— With the help of the staffs of the
AMA and the WVSMA, our
membership recruiting activities
have increased, and the student
and resident sections are growing
in representation both at the state
and national levels.

President's Page

Where do old presidents go?

— New workshops, seminars and
other activities have been
developed for WVSMA members.
The WVSMA staff members are
truly the nuts-and-bolts behind
these activities.

— Our Alliance continues to be a
vital force in representation for
the practice of medicine.

— Members have dramatically
doubled their contributions to
WESPAC, and the WESPAC Board
has been restructured to allow
increased participation.

I could mention many other things,
but I think the most important
information you need to know from
me is how I will continue to serve the
WVSMA throughout the coming years.
Even though I spent the two years
preceding my inauguration on the
Executive Committee as all presidents
have, I did not actually come to
realize the true needs of the WVSMA
until I was president.

As I step down from this office, I
assume responsibility for the Council.
It is in this body of members that I
feel the true strength of the WVSMA is
contained. My responsibility will be to
see that the Council continues to
become a stronger governing body for
the WVSMA.

I would like to jump start the
activity of our Council. You can help
by attending meetings, as well as
serving as councilors, members or
chairs. Our committee structure comes
from the Council and must be
enhanced. New ideas and the fine
tuning of old ones should also come
from Council members.

I feel that coordinating the Council
meetings with other activities, such as
committee meetings and leadership
workshops for county officers, will
encourage increased participation.

This will provide for efficiency in time
and an opportunity for networking. I
also want to attempt to improve
communications by providing reports
which outline actions at Council
meetings for each component society
to review at their local meetings. In
order to be effective, we must
continue to expand the Council’s role.

A year is only time enough to learn
the job. I’m grateful to you and the
WVSMA for giving me this opportunity.
My only regret is that I was not able
to be WVSMA president on a full-time
basis and had to share this last year
with my practice. I look forward to
serving as chairman of your Council.

Thank you for a great year!

James L. Comerci, M.D.

334 THE WEST VIRGINIA MEDICAL JOURNAL

Editorials

James L. Comerci, M.D.

Jim will certainly be missed after he
turns over the reins this month. He’s
been around a bit longer than most at
this point. As president-elect, he spent
a good part of the previous year
directly involved with WVSMA affairs —
standing in for Bob Pulliam who for
many months vainly occupied himself
attempting to talk some sense into his
colleagues in the West Virginia House
of Delegates. Besides, Jim is pretty
easy to get used to.

It’s probably his manner that most
distinguishes him. Jim is not what
anyone would call pushy, just quiet
and firm. Dealing with him, one
quickly finds that he is not inclined to

Oxymoronic

An oxymoron is a fascinating figure
of speech in which contradictory
terms are combined, deriving from the
Greek words oxys - sharp, and moros -
dull. In effect — pointedly foolish.
Managed care qualifies as an
oxymoron. Real care cannot be
managed.

My neighborhood service station is
named Colonial Exxon, but the only
colonials on the scene are the George
Washington Patriots from the local
high school.

Hospitals dispense memoranda
headed Downtime Update. I received
a letter from a consultant in which he
stated he would keep me posted
regarding a patient's recent future.

Jumbo shrimp are advertised in
restaurants. We describe interpersonal
relationships as bittersweet, with
cruel kindness and tough love. We
discuss smokeless cigarettes, living

issue edicts or even engage in a lot of
chit chat. He listens. He gives his ears
a chance. He asks questions. He is as
likely to be found talking to the little
people as to the high and mighty.

Journal readers will have noted that
during the past year, we have had an
extremely articulate and very literate
spokesman occupying our President’s
Page. His one overriding theme
throughout the year on that page has
been ORGANIZATION. Nothing is
more important to Medicine at this
time than organization at the county,
state and national levels.

Because of leaders such as Jim
Comerci, Medicine has probably

wills, best educated guesses,
functional limitations, and are often
found missing.

We are particularly inventive with
respect to descriptions of death and
dying, using euphemistic language such

as unsuccessful resuscitation,
expire quietly, and uneventful death

to somehow modify or soften the
impact. Dying abruptly and being
successfully resuscitated qualifies as a
state of post sudden death.

Nowhere are oxymorons used as
frequently as in neurological disorders.
Dr. Babinski would be puzzled to read
in a hospital chart that his famous sign
was downgoing. Can one really have
unsteady balance, absent reflexes,
incomplete paraplegia and occluded
blood flow?

A final word concerning managed
care. Americans are preoccupied with

escaped the disaster intended for it
this year by the Clintons. The Clintons
will hopefully go away by 1996, but
the country is full of clones who will
continue their socialist endeavors.
Without the organization urged by Dr.
Comerci, they will succeed where the
Clintons have failed.

Jim is a learner — and he is a good
student. He is the first to tell anyone
how much he has learned this year.
We hope the WVSMA can have the
benefit of his knowledge and wisdom
in leadership positions for years to
come.

Stephen D. Ward, M.D.

Editor

the prospect of health care reform. It
seems that something will be done.

Should we scrap the best existing
health care system for an unproved,
even untried system of government
controlled managed care? How can
we destroy our present health care
system for one with no funding and
no price tag which in essence will
eliminate a trip to the office of your
personal physician as an option?

Managed care is not even a
proven hypothesis, but the
American public is buying it with
rampant apathy. Private practice,
fee-for-service, primary care internal
medicine cannot survive under the
proposed reforms. As Yogi Berra says,
“It ain’t over ‘til its over.” It’s over!

John M. Hartman, M.D.

AUGUST 1994, VOL. 90 335

Burton to be installed as WVSMA president

Huntington neuroradiologist Denny
M. Burton, M.D., will take the
presidential oath of office on Saturday,
August 20, during the Second Session
of the WVSMA House of Delegates at
the WVSMA’s 127th Annual Meeting at
The Greenbrier in White Sulphur
Springs.

Born in Marietta, Ohio, Dr. Burton
attended Marshall University in
Huntington for two years and then
transferred to Duke University in
Durham, N.C., where he received a
B.S. degree in zoology in May 1977.

He then returned to Marshall to obtain
his medical degree, which he received
in May 1981.

Dr. Burton completed postgraduate
studies in diagnostic radiology with
special competence in nuclear radiology
at the West Virginia University I Iospital,
where he served as chief resident from
July 1, 1984 - December 31, 1984. He
furthered his studies as a fellow in
neuroradiology at the University of
Washington Hospitals in Seattle from
July 1, 1985 - June 30, 1986. During
his fellowship, Dr. Burton was also an

Burton

acting instructor in the Department of
Radiology at the University of
Washington Hospitals.

Since 1986, Dr. Burton has been a
clinical assistant professor of radiology
at the Marshall University School of
Medicine In addition, he serves on the
Marshall faculty as a clinical assistant

professor in both neuroanatomy and
pediatrics. At the present time, Dr.
Burton is also medical director of Tri-
State MRI and is a neuroradiologist for
Radiology, Inc., both of which are
located in Huntington.

Dr. Burton has been a member of
the WVSMA Insurance Committee and
the WVSMA Professional Evaluation
Committee since 1988. He has served
on the WVSMA Council since 1990,
and in August 1992 was elected WVSMA
vice president, and then president-
elect in 1993. Dr. Burton is a past
president of both the West Virginia
Radiological Society and the Cabell
County Medical Society.

Board certified by the American
Board of Diagnostic Radiology, Dr.
Burton is a senior member of the
American Society of Neuroradiology
and is a member of the AMA, the
Radiologic Society of North America,
the American College of Radiology,
and the Roentgen Ray Society. Dr.
Burton is currently the president of
the Marshall University School of
Medicine Alumni Association.

WVSMA’s 127th Annual Meeting

August 17-20

The Greenbrier ♦ White Sulphur Springs, W.Va.

Special Thanks!!!

The WVSMA staff would like to recognize the members of this year's Annual Meeting Program Committee for the effort put forth
by each individual. The time and initiative taken by these members goes beyond expectations and is sincerely appreciated by the
staff and all those who have the opportunity to participate in the Annual Meeting:

John D. Holloway, MD, Chairman

Constantino Y. Amores, MD
Thomas H. Chang, MD
James L. Comerci, MD
C. Richard Daniel, MD
Chinmay K. Datta, MD
Erlinda De La Pena, MD

David A. Denning, MD
Ahmed D. Faheem, MD
Robert A. Gustafson, MD
Michael J. Lewis, MD
Maurice A. Mufson, MD
Lee L. Neilan, MD

Ex-Officio Members

David Bailey, MBA, CME - Marshall University, Huntington
Kari Long, CME - West Virginia University, Morgantown
Robin Rector, CME - West Virginia University, Charleston

Edward Pinney, MD
Carole Scaring. WVSMAA President
Stephen L. Sebert, MD
Mabel M. Stevenson, MD

336 THE WEST VIRGINIA MEDICAL JOURNAL

“No Needles” program expands statewide

“SAA# THE CAN"

In September, the No Needles in
the Trash Program which was started
last July by Kay Lowers of the Good
Samaritan Clinic in Parkersburg, will
expand to 10 cities in the state.

This program provides free
environmentally safe 1.7 quart
containers for disposal of
needles/lancets and other “sharps”
used in the treatment of diabetes.
Lowers created the service “to show
diabetes patients they can control
their diabetes and help them have
and maintain a positive attitude.”

Until the No Needles program was
developed by Lowers, about 95
percent of sharps in the state were
being thrown away with other
household trash. Many patients were
disposing their sharps in sealed
containers, but they weren’t puncture-
proof. The free containers distributed
by pharmacies for the No Needles
program are puncture-proof, pressure-
resistant, and leak-proof.

For more details, phone Lowers at
(304) 428-6983.

Canaan Valley site for
EMS directors course

The West Virginia Chapter of the
American College of Emergency
Physicians (WVACEP), Regional Medical
Services, Inc. of Fairmont, and the
Center for Rural Emergency Medicine
(CREM) of WVU will be conducting
the first course for medical directors in
West Virginia from September 25-27 at
Canaan Valley Resort and Conference
Center in Davis, W.Va.

This conference is being presented
for professionals who influence
emergency health care, and is
developed with the intent of addressing
the needs of physicians who serve as
EMS medical directors. Physician
assistants who occasionally work with
physicians to provide medical direction
are also encouraged to attend.

Approved for 17.75 hours of ACEP
CME credit, this course will feature
lectures on “Medical Control,” “Quality
Assurance in EMS,” “EMS Systems
Management,” “Emergency Medical
Dispatching," “EMS Systems Design,”
“EMS Communications,” Prehospital
Ground and Air Transport,” “Prehospital
Personnel Education,” "Mediocolegal
Concerns in EMS,” “Disaster Medical
Services,” “Prehospital Research,"
“Injury Control in EMS,” and "Local
EMS Issues.”

For a brochure or registration
information, contact Cathy Coster of
the WVACEP at (304) 366-8764.

SAGES offers GI
endoscopy session

The Society of American
Gastrointestinal Endoscopic Surgeons
(SAGES) has developed a course on
Flexible GI Endoscopy to encourage
and facilitate the practice of intraluminal
(GI) endoscopy by surgeons. This
seminar will be held in Cleveland on
September 10-11 at the Stouffer Tower
City Plaza Hotel and Mt. Sinai Medical
Center Hospital.

Designed to provide a comprehensive
review of diagnostic and therapeutic
endoscopy with an emphasis on
clinical applications and current
practice trends, this program will be
divided into lecture and laboratory
sessions. Registration is available for
the lecture only on September 10.

CME credits are 6.75 hours for the
lecture and 6 hours for the lab.

For additional information and
registration, contact SAGES at 2716
Ocean Park Blvd., Suite 3000, Santa
Monica, CA 90405, (310) 314-2404.

RNSA schedules 80th
scientific assembly

The 80th Scientific Assembly and
Annual Meeting of the Radiological
Society of North America (RSNA) will
be presented Sunday, November 27,
through Friday, December 2, at
McCormick Place in Chicago.

The RSNA meeting is the largest
medical meeting in the U.S. and the
largest radiology meeting in the world.
Last year, more than 54,000 health care
professionals from 94 counties attended.
More than 1,300 scientific papers will
be presented this year — from the latest
findings about mammography to
research breakthroughs in cancer
treatment to new imaging techniques
that avoid the need for surgery. In
addition, nearly 1,500 technical and
scientific exhibits will be on display.

Early registration is suggested due
to limited downtown hotel space. For
more details, phone 1-800-424-5249-

NRHA announces fall
conference series

The National Rural Health
Association has scheduled its Fall
Conference Series for 1994. The series
consists of three conferences designed
to' offer the most up-to-date information

on three specific topics relating to
rural health and rural health care.

The first conference is entitled "Hoe
Ups and Downs of Rural Health Care"
and is scheduled for September 21-23
in Chester, S.C. The other two seminars
will be: "The Second Annual Conference
of Rural Health Clinics , ” September
29-October 1 in Arlington, Va.; and
the "National Conference on Community
Development, ” December 8-10 in
Minneapolis, Minnesota.

For registration brochures, phone
(816) 756-3140.

ACPE offering special
health care awards

Now in its third year, the Awards
Program of the American College of
Physician Executives is again seeking
entrants who believe they may have
demonstrated a way to improve the
quality of care or manage health care
costs.

Entry deadline is August 31, and
entry forms and instructions are
available from the ACPE by calling
1-800-562-8088. ACPE is a non-profit,
national organization of physicians in
leadership and management positions
throughout the health care field. ACPE
holds a seat in the AMA House of
Delegates and has over 9,000 members.

AUGUST 1994, VOL. 90 337

THE GREENBRIER WELCOMES
THE WEST VIRGINIA STATE
MEDICAL ASSOCIATION

Working together is a West Virginia
tradition; building strong partnerships,
contributing to a better future for us all.
The Greenbrier is proud to be a
part ol this tradition and
prouder still to host your meeting.

We look forward to welcoming you
to The Greenbrier.

For information or reservations call
(800) 624-6070 or (304) 536-1110.

West Virginia 24986
A CSX Resort

A member of

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1994-95 WVSMA Delegates/Alter nates

BOONE (2)

Delegate: Ron Stoll ings
Alternate: Ernesto Yutiamco

BROOK (2)

Delegates: W. T. Booher, Pasty Cipoletti
Alternates: Names not submitted

CABELL (16)

Delegates: Nazem Abraham, A. Esposito, A. A.
Garmestani, Adel Ibrahim, William Lavery, Sandra Echols
Marshall, Charles McKown, Jose Ricard, Jack Steel,

Phillip Stevens, Deleno Webb, Elaine Young
Alternates: Hans G. Dransfeld, Hans W. Dransfeld,
William Echols, Gary Gilbert, Panos Ignatiadis, Denise
Kirkland, Robert Marshall

CENTRAL WV (3)

Delegates: Rigoberto Ramirez, Arturo Sabio, Stephen
Smith

Alternates: Clemente Diaz, Arnold Gruspe, Joseph B.
Reed

EASTERN PANHANDLE (4)

Delegates: Edward F. Arnett, Edward L. Pinney, Jr., C.

Vincent Townsend

Alternates: Names not submitted

FAYETTE (2) Names not submitted

GREENBRIER VALLEY (3)

Delegates: Jason Amar, Alan Lee, Stephen Thilen
Alternates: Names not submitted

HANCOCK (3)

Delegates: Charles Capito
Alternates: Names not submitted

HARRISON (5)

Delegates: Thomas H. Chang, Cordell A. De La Pena,
Erlinda L. De La Pena, Saad Mossallati, David Waxman
Alternates: Names not submitted

KANAWHA (19)

Delegates: Ronald E. Cordell, W. Alva Deardorff,

Donald Farmer, Michael Fidler, Sherman E. Hatfield,

Fred Holt, Lester Labus, Michael Lewis, Jimmie Mangus,
John Markey, Samuel Oliver, Jr., Stephen Perkins, Lee
Neilan, David Ritchie, William Sale, Joseph Skaggs,

Ralph Smith, Elizabeth Spangler, James Spencer
Alternates: Shawn Chillag, Lewis McConnell, Jose
Serrato, Tom Sporck, Samuel Strickland, Caroline
Williams

LOGAN (3)

Delegates: Usha Reddy, Plaridel Tordilla, Rajendra
Valiveti

Alternates: Livia Cabauaton, Ernesto Manuel

MARION (4)

Delegates: Irene Blacksberg, Joedy Daristotle

Alternate: John Leon

MARSHALL (3) Names not submitted

MASON (2) Names not submitted

MCDOWELL (2)

Delegate: Alexander Herland
Alternate: Names not submitted

MEDICAL STUDENT SECTION
Delegate: David C, Faber
Alternate: Dominic Cottrell

MERCER (4)

Delegates: Keith Edwards, Arthur Gindin, Gopal M.
Pardasani

Alternates: Names not submitted

MONONGALIA (20)

Delegates: Roger A. Abrahams, Robert D’Alessandri,
Glen F. Aukerman, Russell Biundo, Paul Clausell,
Anthony G. DiBartolomeo, James D. Helsley, Richard
Kerr, Roger E. King, Paul F. Malone, David Z. Morgan,

R. John C. Pearson, John Prescott, V. K. Raju, Stephen L.
Sebert, Mary Ann Sens, Jeffrey A. Stead, James
Stevenson, Richard M. Vaglienti, Herbert Warden
Alternates: James Arbogast, John Brick, John Frich,
Douglas Glover, John Jakubec, Stanley Kandzari,
Howard Kaufman, William Neal, Stephen Powell,
Kimberly Stearns, Stephen Wetmore

OHIO (11)

Delegates: Robert Altmeyer, Dennis Burech, Terry L.
Elliott, Michael Fortunato, John D. Holloway, Thomas
Gary Kenamond, Steve Miller, Martin Reiter, Richard
Terry, Harry Weeks, Daniel Wilson
Alternates: Hugo Andreini, David Bowman, Barton
Herschfield, David Kappel, Carl Kite, Derrick Latos,
Dennis Niess, Jeffrey Shultz, William Strauch

PARKERSBURG ACADEMY (8)

Delegates: Bill Atkinson, David Avery, Robert Gustke,
Harry Shannon, Rutherford Sims, Richard Yocum
Alternate: Paul Burke

POTOMAC VALLEY (2) Names not submitted

PRESTON (2)

Delegates: Darryl L. Landis, Max Harned
Alternates: Paul Getty, Robert Palguta

PUTNAM (2) Names not submitted

RALEIGH (7)

Delegates: Anthony Dinh, Ahmed Faheem, Wallace
Johnson, Iligino Salon, William Scaring, Rajnikant Shah,
Norman Taylor

Alternates: C. Richard Daniel, Jr., Lewis Fox, Cecil
Graham, Lamberto Maramba, Husam Nazer, Jose
Romero, Nancy Webb

RESIDENT PHYSICIAN SECTION
Delegate: Kurt Palazzo, M.D.

SOUTH BRANCH VALLEY ( 2) Names not submitted

SUMMERS (2) Names not submitted

TUG VALLEY ( 2 ) Names not submitted

TYGARTS VALLEY (4)

Delegates: Karl Myers Jr., Mary Myers, Joseph
Tavolacci, Christopher Villaraza, Jr.

Alternates: Stanley S. Masilamani, Joung W. Rhee,
Samuel M. Santibanez

WESTERN (2) Names not submitted

WETZEL (2) Names not submitted

WYOMING (2)

Delegate: Paramjit Shergill

AUGUST 1994, VOL. 90 339

1994 WVSMA Annual Meeting Exhibitors

BOOTH #1 BOOTH #28

NOVA CARE

SEARLE

Yvonne Brown, Patty Pearson, Sue Walker

BOOTH #2

Susan Glover, Natalie Egnor, Michelle Goode

BOOTH # 31
PFIZER LABS

SOUTHERN MEDICAL ASSOCIATION

Paul Lenz, Bill Kenzo

Chip Dawson

BOOTH #3

BOOTH #32

WVU DEPARTMENT OF OB/GYN

WYETH OB/GYN DIVISION

Ann Dacey

BOOTH #4

FAMILY MEDICINE FOUNDATION OF WV

BOOTH #33
GLAXO, INC.

Chris Ferrell, Robert D. Hess, M.D.

Tom Keeney

BOOTHS #8 & 9

WV BUREAU OF PUBLIC HEALTH

BOOTH #34

ACORDIA PAUL REVERE

Cathy Lee

Pete White, Bill Law

BOOTH #10

MARION MERRELL DOW, INC.

Gary Humphrey, Jeff Ball

BOOTH #35
UNCARE, INC.

Jeff Irwin, Robin Farley, Tammy Snopps,
Kathy Nestor, John Vanooteghem

BOOTH #13

MERCK & COMPANY, INC.

I Iarold Ashworth

BOOTH #36

BRISTOL MYERS SQUIBB
(FORMERLY BRISTOL LABORATORIES)

BOOTH #15

John Hymen, Jose Testa, Thomas Brickson

DERMIK LABORATORIES

Kenneth Bliss

BOOTH #37

ADVANCED ORTHOPEDIC TECHNOLOGIES, INC.

BOOTH #16

Gerald K. Lett, William T. Lovegreen, James A. Mazza

I.C. SYSTEMS, INC.

Dick Ledford, Bruce Brindle

BOOTH #38

U.S. ARMY MEDICAL DEPARTMENT

BOOTH #17

Captain Michael LeDoux

CENTER FOR ORGAN RECOVERY AND EDUCATION

BOOTH #39

(CORE)

SYNTEX IABORATORIES, INC.

Jan Aston, Jody Mohr

John Fannin, Ron Goodwin, Dave Morris

BOOTH #18

RHONE POULENC RORER PHARMACEUTICALS, INC.

BOOTH #40
PFIZER ROERIG

Greg Sargent, Earl Lawson, Ralph Kiger

Kelly Vincent

BOOTH #19

RHONE POULENC HOSPITAL DIVISION

BOOTH #41
W.B. SAUNDERS

Michael Ball, Bob Celentano

David J. Prox, Connie S. Prox

340 THE WEST VIRGINIA MEDICAL JOURNAL

BOOTH #42

ROSS PRODUCTS DIVISION

Norman Craig

BOOTH #43

ROBERTS PHARMACEUTICALS

James M. Hicks

BOOTH #44

ROCHE LABARAT ORIES

Marianna Mira, Pete Francesa, Ed Davis

BOOTH # 45

OLSTEN KIMBERLY QUALITY CARE

Suzanne Fink, Alice Sweatman, Lynn Bailey

BOOTH #46
RMI, LTD.

David Haden

BOOTH #47

THE P.I.E. MUTUAL INSURANCE COMPANY

Joel Wendland, Ed Lynch, Len Bitner

BOOTH #48
J. B. LIPPINCOTT CO.

Joe Aulette, Shirley Aulette

BOOTH #49

INTEGRATED DOCUMENT MANAGEMENT, INC.

Mike Collett, Edward Rawson

BOOTH #51

ROBERT C. BYRD HEALTH SCIENCES CENTER

Kari Long, Suzanne Nowell, Julie Moore

BOOTH #52
MERRILL LYNCH

Hal L. Darnold, Gary R. Bird

BOOTH #53

SMITH KLINE BEECHAM PHARMACEUTICALS

Tom McGinley, Jeff Holland, Jon Lipps,

Terry Adkins, Bill Griffin

BOOTH # 54

WYETH AYERST LABORATORIES

Kathryn Ballard

BOOTH #55

MARSHALL UNIVERSITY SCHOOL OF MEDICINE

Gay Jackson, Beth Hunt

BOOTHS #56 & 57
ACORDIA OF WEST VIRGINIA, INC.

Tamara Lively, Rob Vass, Heather Sipes,

Tim Mitchell, Mike Hovis

MEDICAL ASSURANCE OF W.V., INC.

(AN AFFILIATE OF MUTUAL ASSURANCE INC.)

Dr. A. Derrill Crowe, Chuck Ellzey,

Tom Phelps, Jim Cates

BOOTH #50

SANDOZ PHARMACEUTICALS

THANKS!!

A special word of appreciation goes to the following firms who have contributed educational grants
or other support for this year's WVSMA Annual Meeting. The support given by these organizations
makes possible the educational emphasis of the meeting:

Acordia of West Virginia, Inc.

MCV Alumni Association

The Chapman Printing Company

The P.I.E. Mutual Insurance Company

CNA Insurance Companies

Roche Laboratories

Ernst & Young

Sandoz Pharmaceuticals

Glaxo Pharmaceutical

Smith Company Motor Cars

The Greenbrier Hotel

West Virginia University School of Medicine

Marshall University Medical School

Wyeth Ayerst/A.H. Robins Company

AUGUST 1994, VOL. 90 341

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Robert C. Byrd Health Sciences
Center of WVU - Morgantown

August 27

“Managed Care in the 90s,” The
Marriott Marquis, New York, PTE*

September 9

“Inaugural John E. Jones Symposium
on Health Policy” (sponsored by the
WVU Office of the Dean ), Robert C.
Byrd HSC of WVLT, Morgantown

September 15-17

“20th Annual Hal Wanger Family
Medicine Conference” (sponsored by
the WVU Dept, of Family Medicine),
Robert C. Byrd HSC of WVU,
Morgantown, and MDTV sites at St.
Joseph’s Hospital, Buckhannon;

Grant Memorial Hospital, Petersburg;
Boone Memorial Hospital, Madison;
Wetzel County Hospital, New
Martinsville; Davis Memorial
Hospital, Elkins; and Braxton County
Hospital, Gassaway*

September 23-24

“The 1 5th Annual Clinical
Ophthalmology Conference”
(sponsored by WVU Dept, of
Ophthalmology and the WV
Academy of Ophthalmology),
Lakeview Resort and Conference
Center, Morgantown

October 7-8

“Pediatric Oktoberfest ‘94”

(sponsored by the WVU Dept, of
Pediatrics), Robert C. Byrd I ISC of
WVU, Morgantown

October 21-22

“Surgery Update” (sponsored by the
WVU Dept, of Surgery and WV
Chapter of the American College of
Surgeons), Robert C. Byrd HSC of
WVU, Morgantown

* Held in conjunction with a WVU football game

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Fairmont ★ Fairmont General Hospital,
Oct. 4, 7:30 p.m. “Pediatric Cardiology
Update,” Stanley Einzig, M.D

Gassaway □ Braxton County Memorial
Hospital, Aug. 24, 6:30 p.m.*

Ijewisburg □ WV School of Osteopathic
Medicine, Sept. 27, “Cryosurgical
Ablation of the Prostate, ” James P.
Tierney, D.O.

Man □ Man Appalachian Regional
Hospital, Sept. 21, 6:30 p.m., “Disease
of the Larynx,” James T. Spencer,

M.D.

Martinsburg ★ VA Medical Center,

Sept. 1, 3 p.m., “Sleep Disorders,”
Robert Keefover, M.D.

★ VA Medical Center, Oct. 6, 3 p.m.,
“Acute Respiratory Failure,” Harakh
Dedhia, M.D.

New Martinsville ★ Wetzel County
Hospital, Oct. 13, noon, “Exercise
Testing for the Primary Care
Physician,” Anthony Morise, M.D.

★ Wetzel County Hospital, Sept. 8,
noon, “Hepatitis,” R. Wesley Farr, M.D.

Oak Hill □ Plateau Medical Center,

Sept. 27, 6:30 p.m., "The Pitfalls in the
Initial Evaluation of the Trauma
Patient,” James W. Kessel, M.D.

Point Pleasant □ Pleasant Valley
Hospital, Aug. 25, noon,

“Cryosurgical Ablation of the
Prostate,” James P. Tierney, D.O.

□ Pleasant Valley Hospital, Sept. 22,
noon, “Medical Emergencies,” Steven
Jubelirer, M.D.

White Sulphur Springs ★ The

Greenbrier Clinic, Aug. 22, 4 p.m.
“Prostate Cancer Prevention Trial,"
Unyime Nseyo, M.D.

★ Tire Greenbrier Clinic, Sept. 26,
4 p.m., "Breast Cancer,” Edward
Crowell, M.D.

★ Tire Greenbrier Clinic, Oct. 24,
4 p.m., “Office Practice of Sports
Medicine,” William Post, M.D.

* To be announced

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342 THE WEST VIRGINIA MEDICAL JOURNAL

Poetry Corner

September

6-11— 18th Annual Meeting of the American
Academy of Neurological and Orthopaedic
Surgeons, Las Vegas

8-10-Surfaces in Biomaterials Symposium
(sponsored by the Surfaces in Biomaterials
Foundation), Scottsdale, Ariz.

8-10-American Gynecological and
Obstetrical Society, Hot Springs, Va.

10-11— Flexible GI Endoscopy (sponsored
by the Society of American Gastrointestinal
Endoscopic Surgeons), Cleveland

10- 13-Seventh Annual Update in Internal
Medicine (sponsored by Ohio State
University), Columbus

11- 14-American College of Emergency
Physicians, Orlando, Fla.
16-17-Communication Approaches for
Tracheostomized and Ventilator Dependent
Patients (sponsored by Voicing!, Inc.),
Louisville, Ky.

21- 23-The Ups and Downs of Rural Health
Care (sponsored by the National Rural
Health Association), Chester, S.C.

22- 23-Tools and Techniques for Improving
Clinical Outcomes: A Practical Seminar for
Physicians and Clinical Leaders (sponsored
by the Joint Commission on Accreditation of
Healthcare Organizations), Atlanta
22-24— First Annual European - American
Conference on Gastrointestinal Oncology
(sponsored by the George Washington
University Medical Center), Bordeaux, France
22-24— American Academy of Facial Plastic
and Reconstructive Surgery, San Diego

22- 25-American Academy of Family
Physicians, Boston

23- 24-Prevention of Target Organ Damage
in the Hypertensive (sponsored by Ohio
State University), Columbus

23- 24-Transfusion Medicine of the Future
(sponsored by the American Association of
Blood Banks), Phoenix, Ariz.

24- 30-XIV FIGO World Congress, Montreal

25- 27-Course for Medical Directors
(sponsored by the WV Chapter of the
American College of Emergency Physicians,
Regional Medical Services, Inc., and the
Center for Rural Emergency Medicine of
WVU), Davis, W.Va.

28- Oct. 1- American Association for the
Surgery of Trauma, San Diego

29- The Three Rs of Environmental Health:
Risk, Reality and Responsibility, the National
Health Council's 41st Annual National
Health Forum, Washington, D.C.

29-Oct. 1-Second Annual Conference of
Rural Health Clinics (sponsored by The
National Rural Health Association),

Arlington, Va.

For More Information . . .

Contact the Journal at (304) 925-034

A Time for Rhyme

I often regret

The passing of the time

When poems would rhyme,

And yet

Modem verse , both blank and free.

Has given me
Many hours of bliss,

(Thanks to modern poets for this).

But verses with rhymes
Recall happier times
When the world was young
And poems were sung.

(here is a rhyming in God's universe
That calls to me for rhyming verse.

Robert L. Smith, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward, M.D.,
Editor, West Virginia Medical Journal P. O. Box 4106, Charleston, WV 25364.

'' X iM&t&T on 6 NiURSE &EIKi6 ?RE£>E.KrT .

AUGUST 1994, VOL. 90 343

Roger K. Pons, M.D.

Colon fr Rectal Surgery

General Surgery

Areas of expertise include colon and rectal cancer,
inflammatory bowel disease, colonoscopy, anorectal disease,
treatment of stool incontinence, hemorrhoids.

Board-Certified, General Surgery

Member, American Society of
Colon & Rectal Surgery

Now in practice at: Physician Office Building Number One

Stonewall Jackson Memorial Hospital, Weston, VVV 26452
Phone 304/269-1686 FAX 304/269-1688

MANAGERS
/ ASSOCIATION

Cuts CPtl k 'idtu, rCo.

Join us for the Eighth Annual Conference

The Business Side of Medicine

November 10-12, 1994

Canaan Valley Resort, Inc.

Davis, West Virginia

Topics include: "But That's the Way We've Always Done it"

"Excelling in Economics"

"Are Your Accounts Receivable Healthy ?--If Not, Here's the Cure"
"Professional Presence, Power and Image"

"The Business Side of Medicine"

"Here Comes De' Judge, Here Comes De' Judge"

Grand Prize Drawing for Early Bird Registration by August 3 1
For registration information contact:

Office Managers Association of Health Care Providers, Inc.

P.O. Box 3850, Charleston, WV 25338 (304)348-2545

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

New resource guide
lists opportunities for
health professionals

Since West Virginia has a shortage of
health care professionals, the Bureau
of Public Health has developed a new
resource guide on the educational and
career opportunities available in the
state.

Published by the Bureau’s Office of
Community and Rural Health Services,
the “ Health Careers Reference Manual''
provides information on health care
careers, as well as descriptions of
occupations, their educational and
training requirements, typical work
activities, work settings, financial aid
resources and professional contacts.

The manual is part of a long range
effort to improve health care service
and delivery in the state by recruiting
and retaining health care professionals
to work in West Virginia. More than

2,000 copies of the manual are being
distributed around the state to school
guidance counselors and vocational
instructors. Copies are also being sent
to libraries, colleges, universities,
hospitals and other health care facilities
in West Virginia. Publication of the
manual was made possible mainly
through a grant from the Claude
Worthington Benedum Foundation.

To obtain a free copy of the manual,
call (304) 558-3210.

Manual outlines clean
indoor air policies

A manual entitled “A Step by Step
Guide for Community Tobacco Control
in West Virginia’ 'is now available from
the Bureau's Cardiovascular Disease
Program to help communities pass
clean indoor air regulations.

This manual provides strategies for
drafting clean indoor air policies,
information on assessing and building
community support for such policies,
and steps for ensuring the enforcement
of local clean indoor air regulations.

To date, ten counties and five cities in
West Virginia have already enacted
clean indoor air policies, and a
number of other counties are in the
process of doing so. Efforts to pass
these policies at the local level have
been effective because residents are
actively involved in promoting and
enforcing the regulations.

Clean indoor air policies protect
non-smokers from tobacco smoke,
which has been proven to cause lung
cancer and heart disease. In 1992, the
U.S. Environmental Protection Agency
classified second-hand smoke as a
Group A carcinogen, a substance
known to cause cancer. As many as

3,000 to 4,000 non-smokers are
estimated to die each year in the
United States from their exposure to
second-hand smoke, and children
exposed to second-hand smoke in the
home are more likely to suffer from
asthma, chronic breathing problems
and ear infections.

A limited number of the free guides
are available by calling Disease
Prevention Director J.T. Morris at
(304) 558-0644. Also at this same
number, details can be obtained on
implementing tobacco control policies
by contacting Tobacco Control
Program Director Joyce Holmes.

Provisional statistics
released for 1993

The Bureau of Public Health's “ West
Virginia Provisional 1993 Vital
Statistics” indicates there were fewer
births, infant deaths and marriages in
the state last year.

Provisional figures show there were
20,722 births to state residents in 1993,
down from 22,156 in 1992. Since the
surrounding states have not yet
completed reports about births to West
Virginians, final birth rates are expected
to be slightly higher. Data also show
that even though births to teenagers
also fell, teen births accounted for
nearly 18% of total births. In addition,
the percentage of low birthweight
babies remained virtually unchanged,
but the percentage of women who
received first trimester prenatal care
decreased slightly to 75.8% in 1993,
down from 76.7% in 1992.

In other vital statistics, the state's
resident death rate of 11.0 per 1,000
population exceeded the 8.8 national
provisional rate. Nearly 35% of all state
deaths were caused by heart disease,
making it once again the number one
killer of West Virginians. The number
of infant deaths fell to 183 in 1993,
down from 201 in 1992, resulting in an
infant mortality rate of 8.8 per 1,000
live births, down from 9.1 in 1992.

While the number of marriages
dropped to 11,671 in 1993, down
from 12,097 in 1992, the number of
divorces remained nearly the same at
9,799. The marriage rate was 6.5 per

1,000 population and the state’s
divorce rate was 5.4 for the second
year in a row.

Final vital statistics will be made
available later this year. For more
information, call the Health Statistics
Center at (304) 558-9100.

Future Conferences

WV Public Health Association

" Public Health Reform:
Making It Happen ”

September 21-23
Parkersburg Holiday Inn
Parkersburg, WV

For more information call:

Karen Hall-Dundas - (304) 523-6483

WV Conference on
Emergency Medical Services

’Wild, Wild West”

September 27-28
Canaan Valley Resort
Davis, WV

For more information call:

Carlo Zando - (304) 558-3956

WV Rural Health Conference

‘Transitions in Rural Health Care:
Successful Survival Strategies”

November 4-6
Lakeview Resort
Morgantown, WV

For more information call:

Tera Thomas - (304) 558-1327

344 THE WEST VIRGINIA MEDICAL JOURNAL

Robert C. Byrd
health Sciences Center

OF WEST VIRGINIA UNIVERSITY

Compiled from material famished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

OB/GYN Department
to create tumor bank,
affiliate with GOG, NCI

The Department of OB/GYN’s
gynecologic oncology division will
establish a gynecologic tumor bank and
affiliate WVU with the Gynecologic
Oncology Group and the National
Cancer Institute.

The bank will be headed by Dr. R.
Gerald Pretorius, associate professor
and director of gynecologic oncology,
and Dr. Andrew Patrick Soisson, who
joined the department in July.

Dr. Soisson comes to WVU from the
gynecologic oncology division at
William Beumont Army Medical
Center in El Paso, Texas. 1 le earned
his medical degree from Georgetown
University and completed a residency
in OB/GYN at Madigan Army Medical
Center in Tacoma, Wash. Dr. Soisson
completed his oncology training at
Duke University Medical Center.

Grant helps establish
Health Sciences and
Technology Academy

The HSC’s Office for Social Justice
received a five-year, $175,000 grant
from the Howard Hughes Medical
Institute to establish a Health Sciences
and Technology Academy (HSTA).

The academy will encourage pre-
college minority and financially
disadvantaged students to enter
careers in the health sciences. “These
are two groups that need better
representation in the health care
professions,” says Ann Chester, Ph.D.,
assistant to the vice president for
health sciences for social justice and
HSTA project director. “They are also
two groups we believe are highly
likely to go back to their communities
to work as health care professionals.”

For more information on HSTA, call
1-800-345-4267 or (304) 293-2895.

Hill named chair of
WVU review board

Dr. Ronald Hill,
professor of
cardiothoracic
surgery, has been
named chair of the
WVU Institutional
Review Board
(IRB) for the
Protection of
Human Research
Subjects.

Dr. Hill has
served on the IRB since 1990. He
succeeds Dr. Irma Ullrich, professor of
endocrinoogy/ metabolism, who
stepped down after serving as chair of
the board for four years.

Pearson lectures at
Romanian conference

R. John Pearson,
M.B., M.P.H.,
professor and chair
of community
medicine, recently
discussed health
care in West
Virginia for his
keynote address
at the annual
meeting of the
School of Public
Health in Iasi, Romania.

Dr. Pearson was the first Westerner
in 45 years to speak at this institution,
and he will serve on the editorial
board of the school’s Journal of
Preventive Medicine.

Kolbenschlag writes
book on gender issues

Madonna Kolbenschlag, Ph.D.,
clinical psychologist for University
Health Service, recently traveled to
Spain to launch the world-wide
publication of her book Kiss Sleeping
Beauty Good-By.

Dr. Kolbenschlag's book, which will
be published in five languages, is on
women’s psychology and gender issues.

Pearson

Hornsby elected to
ADA board of directors

W. Guyton
Hornsby, Ph.D.,
assistant professor
in the exercise
physiology program
of the Department
of Medicine, has
been elected to a
three-year term on
the American
Diabetes Association
Board of Directors.
Dr. Hornsby has been actively
involved in the ADA for many years.

He has been instrumental in advancing
the use of exercise in diabetes care.

Ramadan presents
two papers at seminar

Ramadan

Dr. Hassan
Ramadan, assistant
professor of
otolaryngology,
recently presented
two papers at a
meeting of the
American
Rhinologic Society
in Palm Beach, Fla.

The two papers
were ' Bacteriology'

of Chronic Sinusitis in Adults, ” and
" Endoscopic Treatment of Acute
Frontal Sinusitis. "

Williams, Heimbach
author BTLS chapters

Dr. Janet Williams, assistant professor
of emergency medicine, and research
director for the Center for Rural
Emergency Medicine, and Leah
Heimbach, CRFM administrator, have
written chapters in the Basic Trauma
Life Support Advanced Prehospital Care
textbook.

Dr. Williams' chapter is entitled
'Injuty Prevention and Control and
the Role of the Prehospital Healthcare
Provider. " Heimbach's chapters are
" Trauma in the Elderly "and “Trauma
Scoring in the Prehospital Setting. ”

346 THE WEST VIRGINIA MEDICAL JOURNAL

Ninth Annual Itauma Conference - Rural IVauma
September 30 - October 1, 1994

Trauma "Down on the Farm" • Mechanism of Mining Injuries • Hunting Injuries • Paralytic Agents in
Rural Transport • Management and Treatment of Dislocations • The Role of Nurse Practitioners in Rural
West Virginia • Initial Assessment and Stabilization in a Rural Setting • Avulsing and Crushing Injuries

Glade Springs Resort and Conference Center
near Beckley, West Virginia

For more information, please contact Continuing Education and Conference Services, (304) 348-9581 .

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Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

Master's degree in
forensic science to be
offered at Marshall

The state’s first degree program in
forensic science — and one of only
about seven master’s-level programs
in the country, will begin at Marshall
in the fall of 1995, according to Dr.
Terry Fenger, acting chairman of the
Department of Microbiology,
Immunology and Molecular Genetics.

The new graduate program in
forensic science is based on molecular
biology and the latest techniques in
DNA typing. It was approved by the
state board of trustees in July.

Dr. Fenger said that Marshall’s
degree program will be unique since
only a few of the 17 established
forensic programs in the country are
master's level, and few, if any, focus on
molecular biology and DNA typing.
“West Virginia has the potential of
being a leader in the development and
use of DNA technologies for forensic
purposes,” he said.

The School of Medicine’s forensic
science division, which Dr. Fenger
heads, has been offering continuing
education classes and performing
forensic work for the state police for
more than two years. A special
$100,000 state appropriation will help
develop the program further.

The division is the first stage in the
development of Center for Applied
Biotechnology which will be directed
by Dr. L. Howard Aulick, assistant
dean for research development. In
addition to forensic science, the
center will include a medical sciences
division and an environmental science
division, Dr. Aulick said. He is
currently looking for a suitable facility
to house laboratories and equipment.

“We hope to collect in one facility a
basic set of molecular equipment and to
apply that core equipment to forensics,
environmental science and medical
diagnosis,” Aulick said. All three areas
utilize similar DNA techniques.

The forensics program will feature a
state-of-the art DNA typing facility with
a cell molecular laboratory designed to
support the accelerating demands of
law enforcement agencies and the
court systems for identity testing. It will
also serve as a training center for the
master’s degree program. Plans call for
using the laboratory to research new
DNA typing techniques as well. Dr.
Fenger said that the forensic program
will use existing facilities on the main
campus and at the School of Medicine
for now, but will need additional
laboratory space to expand into the
research area.

The medical sciences division,
which will be directed by Dr. Richard
Niles, chairman of the Department
ofBiochemistry and Molecular Biol-
ogy, will feature an Advanced Medical
Diagnostics Laboratory as an exten-
sion of the DNA typing facility. It will
provide both DNA-based and non-
DNA-based clinical diagnostics,
emphasizing assays for cancer,
infectious diseases and genetic
diseases. Only those educational,
research and clinical services not
available at existing local medical
facilities will be offered.

A market survey being developed by
the College of Business will determine
what advanced diagnostic tests are
needed locally. “Instead of sending to
New Jersey for these tests, hospitals
will be able to have them perfomied
right here,” Dr. Aulick said.

The medical sciences division will
also provide training in advanced
DNA protocols for MLJ clinicians and
conduct research on new diagnostic
tests. “Dr. Niles is interested in and
committed to bringing biotechnology
and the biotechnology industry to
Huntington,” Dr. Aulick remarked.

Other research planned for the
center would explore the genetic
basis for diseases common in West
Virginia, such as hypertension,
obesity and cancer. Dr. Aulick
pointed out that such research ties
into the school’s rural health initiative
and could build on groundwork
already laid in places like Lincoln
County. The environmental science
division will focus its research on
environmental assessment and
reclamation, he added.

MARSHALlVONIVERSITY

Study shows dramatic
economic impact of
health care in Tri-State

A new Marshall University study
released by MU President J. Wade
Gilley indicates that the health care
industry's economic impact on the Tri-
State area amounts to more than $1.1
billion annually and 27,000 jobs.

The study was headed by Marshall's
Distinguished Professor of Management
Robert P. Alexander and funded by the
Marshall's Research and Economic
Development Center. It covers Cabell
and Wayne Counties in West Virginia,
Lawrence County in Ohio, and Boyd,
Greenup and Lawrence counties in
Kentucky.

Direct expenditures by the health
care industry totaled $642,247,600.
Applying the standard multiplier effect
resulting from respending of these
dollars, the total economic impact was
$1,104,665,900, Alexander said. Health
care provided 11,767 jobs directly
with secondary jobs bringing the total
to 27,488, generating household
incomes amounting to $505,641,500.

MU's practice group
adopts new name

Marshall physicians have changed
the name of their practice group to
University Physicians and Surgeons.

The new name, which replaces the
name John Marshall Medical Sendees,
provides a common thread that will
make it easier to recognize the many
area offices in which faculty members
treat patients, said James Schneider, the
school’s associate dean for finance and
administration.

With LJniversity Physicians and
Surgeons as the umbrella organization,
offices run by individual departments
will use variations such as University
Pediatrics and University Family
Physicians.

"We would like to create a more
unified public image for our clinical
departments before we make our
proposed move into consolidated
facilities,” Schneider said.

348 THE WEST VIRGINIA MEDICAL JOURNAL

Just

WESPAC

Do It!

Don't wait, the time to act is now!

Send your personal check to WESPAC and
become involved!

WESPAC
P.O. Box 4106
Charleston, WV 25364
304/925-0342

Checks for all PAC contributions should be payable to WESPAC. If
your practice is a corporation or professional association, contribu-
tions must be written on a PERSONAL check. Contributions are not
limited to the suggested amount. Neither the AMA. the WVSMA nor
the component medical societies will favor or disfavor anyone based
on the amount of or failure to make PAC contributions. Contributions
are subject to Federal Election Commission Regulations and the West
Virginia Secretary of State Regulations.

Contributions for WESPAC/ AMPAC are not deductible as charitable
contributions for federal income tax purposes. A portion of your
WESPAC contribution is sent to AMPAC thus enrolling you as an
AMPAC member as well.

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Alliance
News

Farewell message

Do you know what was great about being the president of the West Virginia State Medical Association
Alliance? Everything! There were places to go, people to meet, and things to do all over the state -- and all the
experiences were a pleasure.

Dr. Jim Comerci and I tried to visit most of the counties in the fall to have the opportunity to meet members,
as well as promote the Alliance and the WVSMA. Two workshops were presented in September by AMA Alliance
Field Director Ann Wrenn. One workshop was held in Morgantown, and the other was in Charleston. We
learned about membership promotion, and Ruth Gilbert gave a minicourse on parliamentary procedure.

During the past year, I represented the Alliance at several national conferences which were educational and
motivational:

1. The AMA National Political Education Conference in Washington, D.C. - Sept. 29-30.

2. Confluence in Chicago - Oct. 3-5.

3. Southern Medical Convention in New Orleans - Oct. 28-31

4. AMA Alliance National Convention in Chicago - June 12-14.

AMPAC has always promoted their Campaign Management School. In March, I spent a week in Washington,
D.C., attending the school. I presented an article in the April issue of xheWest Virginia Medical Journal, which
gave my account of the most extraordinary week of my life. Read it before you plan to attend the school.

The Fall Board Meeting at Hawks Nest State Park, and the Spring Board Meeting at the Days Inn in Flatwoods,
were well attended. These places were ideal for meetings, and we received royal treatment.

Many counties produced health projects that benefited their counties. I would still encourage the county health
chairmen to contact their local health departments to help solve the needs in their communities.

The WVSMAA became a member of the West Virginia Tobacco Control Coalition this year. There are 60
organizations who belong to this coalition. They were impressed with our lobbying skills and the legislative
phone bank that we used in promoting health legislation this year.

It has been a pleasure to work with the staff at the the WVSMA. They all were available at a moment's notice
to answer any question. They made me feel comfortable with their friendly dispositions and smiling faces. I
could tell they all like their jobs and take pride in their work. There is a definite atmosphere of cooperation.

Special thanks to Winnie Morano, who serves as the WVSMAA executive secretary and director of government
relations. She helped reorganize WESPAC, writes and edits WESGRAM, the Legislative Update, and MedLink. She
does a great job in all these areas. If I had not had Winnie to help me, I would not have been able to accomplish
my goals.

I attended all the WVSMA's Council meetings this year. It was an honor to be allowed to have a vote at these
meetings, but I also appreciated being asked to give my opinion during various discussions.

WVSMA President Dr. Jim Comerci, with his calm, hardworking style, was always interested in what was being
done in the Alliance. He always made me feel as though the WVSMA and WVSMAA are partners working to
make West Virginia a better place to work and live.

I want to also thank all my officers and board members. It is wonderful to have people who know their jobs
and do them well. Without a doubt, I feel as though 1 have been the president of the best organization in the
state because of the superior quality of the members of the WVSMA Alliance.

Carole Scaring

WVSMAA President, 1993-94

350 THE WEST VIRGINIA MEDICAL JOURNAL

West Virginia Medical

September 1994

UNIVERSITY OF MARYLAND
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EDITOR

Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Postmaster send form 3579 to the West
Virginia Medical Journal, 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL IOURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $36 a year in the U.S.;
$60 in foreign countries; $3 per single copy.
Address communications to the West
Virginia Medical Journal, P. O. Box 4106,
Charleston, WV 25364.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Road,
Ann Arbor, MI 48106.

West Virginia Medical

OURNAL

Contents

Feature Article

Lessons from the Swedish health care system 362

Scientific Newsfront

West Virginia Physicians: Cardiovascular

risk factors, lifestyles and prescribing habits 364

A study of helicobacter-pylori in 100 pediatric

patients from the Tri-State area 367

A combined internal medicine - psychiatry clinic

at a community hospital: Initial experiences 370

President’s Page

Change and the herding of cats 374

Editorials

Contemplating the complexities 375

Letters to the Editor

The legal responsibility of physicians supervising

physician assistants is significant 376

Some questions for Senator Rockefeller 376

Special Departments

General News 378

Continuing Medical Education 382

Medical Meetings/Poetry Corner 383

Bureau of Public Health News 384

Robert C. Byrd Health Sciences Center of WVU News 386

Marshall University School of Medicine News 388

Medical Student Section 390

WESPAC Members/New Members 392

Classified 393

September Advertisers 394

USPS 676 740
ISSN 0043 - 3284

Front Cover

Bees make their nightly visit to a datura flower in the
garden of Paul and Nancy Hill of Charleston. Photo
courtesy of Nancy Hill, managing editor of the West
Virginia Medical Journal.

SEPTEMBER 1994, VOL. 90 361

Lessons from the Swedish health care system

BRIAN J. CAVENEY

Accepted to West Virginia University Medical
School, Morgantown

Editor’s Note: Brian Caveney
recently visited Sweden for 1 6 days
with a group o/U.S. health care
professionals and government
leaders to study the country’s health
care system. In 1991, he visited
China to observe traditional Chinese
medicine, and that same year he
was also selected by USA TODA Y as
one of 20 academic All Americans.

Sweden’s nationally-controlled
system of health care has often been
envied by other countries and touted
as a possible option to our current
system in the United States. However,
during the past decade many major
problems have arisen with the delivery
of health care in Sweden, and multi-
level reforms have been introduced in
an attempt to improve the system’s
efficiency and quality. Even with these
reforms, though, Sweden’s system of
health care is not an option in the
United States for many reasons.

The Swedish health care system was
founded on a needs-based, command-
and-control model in which national
and regional government planners
allocated money and personnel
according to demographic and
epidemiological patterns. The system
has traditionally operated under the
fundamental principle that all citizens
deserve equal access to health and
medical care. Responsibility for care has
been the duty of 23 county councils
and accounts for 75%-80% of the total
expenditure of most county councils.

The quality of care in Sweden has
not been comprehensively measured,
but the health of the population is
relatively good by international
standards. The infant mortality rate is
the world’s lowest and its life
expectancy rate is the highest (1).

Over the years, though, the need for
progressive reforms has been dramatic
due to the aging of the country’s
citizens, expensive technological

improvements and constrained public
sector budgets. In addition, other major
problems exist with the system because
of its lack of freedom of choice for the
patients; its inaccessibility to primary
health care; its low productivity
because of a lack of incentives and
conflicting roles; and its lack of quality
control and monitoring (2). The Swedish
Institute also considers other problems
inherent with the system such as long
waiting lists for certain procedures,
lack of integration between certain
divisions of the social insurance
organization; and a faulty primary care
system with a high proportion of
direct referrals to hospitals (1).

In an article entitled “Towards a
Swedish Health Policy for the 1990s:
Planned Markets and Public Firms, ”
Otter and Saltman made the point that
the Swedish system was unable to
meet the fundamental needs of the
patient in spite of sufficient funding (3).
Otter and Saltman also stated that
uninformed politicians should allow
the organization of operational
activities to be the responsibility of
health care professionals. In addition,
the Swedish Institute also faulted the
system for not having any measures in
place for evaluation of services (1).

The necessity for reform was a
political consensus that was recognized
in the late 1980s, but the first major
actions were not introduced until
1992. The Public Health and Medical
Service Committee of the Stockholm
County Council released a leaflet
called “The Stockholm Model” which
decribed these new organizational and
theoretical principles (4).

The key attribute of this model was
the placement of the patient at the
center, which significantly increased
the rights of the patient. This new
mandate gave patients the freedom to
choose their family doctor, their health
clinic, specialists and hospital, whereas,
previously patients were assigned to
sites in their immediate geographical
area. In addition, the Stockholm Model
stated that no one was to wait more
than three months for certain surgical
procedures; the number of family
doctors was to be increased so on-call

service could be offered; patients did
not have to pay more than 1,600
Swedish crowns (about $200) in health
care costs in one year; medical audits
were to be installed to insure quality
care; and patients were given the right
to legally appeal any treatments they
considered improper.

These many reform elements were
implemented under the premise of
equality in health care, a longer and
healthier life, and equal access to high
quality care (4). According to Thorslund,
“Sweden will remain a welfare state,
but the fundamental commitment to
universalism will be diluted and
selectivity will creep in” (5).

In an interview on June 16, 1993,
Jan-Ake Andren of the Stockholm
County Council Health and Medical
Care Unit stated that the measures
taken in the Stockholm Model were
designed to save money by increasing
productivity, by placing age limits and
priorities on certain procedures, by
raising the amount of fees covered by
the patient, and by exploring private
insurance and financing to make up
further discrepancies. He stated that
these actions showed that their
nationalized system raised the patients'
medical care costs through taxes and
lowered the number of services
available - an outcome which
American physicians fear would be the
result of nationalized care in the U.S.

The short-term consequences of the
reforms in Stockholm County did
provide support for patient choice.
Currently, all individuals can pursue
alternative treatment sites if they
desire. For example, 15% of Sweden’s
expectant mothers select a hospital
other than the one in the geographical
area to which they would previously
have been assigned. This fact has
encouraged maternity wards to offer
different techniques for childbirth that
are more popular with women — a
change which has actually improved
the coordination between clinics and
maternity primary care offices,
according to Otter and Saltman (3).

The problems that triggered some
of the reforms in the Stockholm Model

362 THE WEST VIRGINIA MEDICAL JOURNAL

serve to indicate that similiar or more
severe problems would arise if the
original plan proposed by President
Clinton or the current Mitchell
proposal were enacted. First and
foremost, certain aspects of Swedish
society have a major impact on the
management and delivery of health
care. Reliance on the government for
support in a society built on the
honor system is certainly contrary to
the individualistic “every man for
himself" attitude fostered in our own
society. The Swedish mindset expects
cradle-to-grave amenities from its
socialized system. Otter and Saltman
suggest that under the pre-reform
organization, there existed a social
democratic concept of equity within
welfare state distributions that expected
the individual to place his needs in a
collective way of thinking, thus creating
a degree of classlessness (3).

These socialistic perspectives, while
inherently present in the Swedish
people, would be logistically impossible
to adopt in American society. Swedish
society enthusiastically has given
priority to the country’s goals of
reducing the number of smokers by
half, reducing the consumption of fat by
one-fourth, reducing the consumption
of alcohol by one-fourth, and reducing
the number of accidents from
environmental and living habits (4).
These public health goals are often
discussed in the United States, but in no
way are they given the attention and
prominence they are in Sweden.

In the United States, the high cost of
health care is due to many factors, but
one of the main reasons is that we tend
to eliminate the conflicts between
medical ethics and financial demands
by opting for continued care and
services. In fact, it has been claimed
that 40% of an American person's
lifetime health care budget is spent
during the last 90 days of his/her life.
This reality is also one of the reasons
that promoted the need for reform of
the Swedish system since it has one of
the highest proportions of elderly
people in the world, with 18% of its
citizens over the age of 65.

Thorslund (4) has recommended
that guidelines be set for limiting the
use of technology in situations where
it is unlikely to be of benefit. This
priority setting and use of age limits
would probably not be tolerated in
America, where increased value is
placed on the last moments of life
without regard for cost. As George
Church noted in an article for Time (6),
“Luxury care will become very rare,
since almost no coverage will pay for it.”

Another difference between the
United States and Sweden is the
incidence of litigation. According to
an 1993 article by Fields published in
Insight (7), the total expenditure for
malpractice insurance in the United
States was $7 billion in 1988, and
estimates indicate that one in 25 doctors
is successfully sued every year. Even
though Senator Rockefeller claims that
malpractice only accounts for 2% of
the total costs incurred, other intrinsic
factors such as defensive medicine
greatly increase the occurrence of
unnecessary procedures and reluctance
to treat potentially litigious patients.

“Right now I’d rather be
in Sweden than in the U.S.
because we are moving
away from the welfare
state. On your side, you
are moving right into it,
and you risk destroying
your country” (8).

This malpractice situation is almost
non-existent in Sweden because
traditionally patients do not question
the knowledge and expertise of their
practitioners. As a result, costs do not
increase because of patients soliciting
second, third and fourth opinions. Since
the exact opposite is true in the U.S.,
it is very obvious that no effective cost
containment is possible without serious
restructuring of tort procedures and
limitations on contingency fees. Fields
implores that we should expect lawyers
to abide by ethical premises like those
stated in the Flippocratic Oath with the
same fervor and conviction expected
from doctors (7).

Possibly as a result of American
influence, the reforms in the new
Stockholm Model granted patients the
right to complain and appeal about
problems to a patient ombudsman at a
hospital, a county council representative
board, or a health care disciplinary
board. This is just one of several
measures that indicate movement
toward the outlines of the traditional
American system of health care.

Other Swedish reforms intentionally
emulate various aspects of the market
system with built-in incentives for the
providers as well as the recipients. The
Stockholm Model exceeds a basic
premise of fee for service and
approaches a system of fee for proven
results. The resulting trend is for
reimbursement to be provided by
personal income financing rather than
government subsidy. This incentive

has already increased productivity by
8% during 1992, while it reduced
surgery waiting lines and times by as
much as 45%. For example, between
1990 and 1992, cataract operations
increased by 220% and hip/knee
replacements by 80% (3).

While progressive reforms are
underway in Sweden, the push to
reform health care in this country
continues to the disbelief of many
Swedes. Ian Wachtmeister, head of
the New Democracy Party which has
recently been elected into office, said
"Right now I'd rather be in Sweden than
in the U.S. because we are moving
away from the welfare state. On your
side, you are moving right into it, and
you risk destroying your country” (8).

After observing the Swedish system
firsthand, I understand how important
Wachtmeister’s statement needs to be
to U.S. leaders and citizens. Even the
writers of the Swedish reforms
acknowledge, on top of all the other
problems I have mentioned, that
nationalized health care has also caused
their country to neglect research and
teaching, and create a large and
inefficient bureaucracy. As Otter and
Saltman have said, care must also be
given to establish the differences
between a commercial commodity
and a professional service such as
public health (3).

In closing, I hope that if any reforms
are made in the U.S., our government
leaders take into account a few maxims
learned in every introductory course
in economics: there is no such thing
as a free lunch — government is never
as efficient at the allocation of
resources as the private sector — and
price controls always lead to less of
the controlled commodity.

References

1. The Swedish Institute. Health and medical
care in Sweden. Fact sheets on Sweden,
October 1991.

2. Diderichsen F. Market reforms in Swedish
health care: a threat to or salvation for the
universalistic welfare state? International J of
Health Services 1993;23(1): 185-8.

3. Otter CV, Saltman R. Towards a Swedish
health policy for the 1990s: planned markets
and public firms. Social Science in Medicine
1991:32(4)473-81.

4. The Stockholm Model. A leaflet distributed
by the Stockholm County Council, Public
Health and Medical Service Committee.

5. Thorsland M. The increasing number of very
old people will change the Swedish model
of the welfare state. Social Science in Medicine
1991;32(4):455-64.

6. Church GJ. Are you ready for the cure? Time
1993 May 24:30-9.

7. Fields S. Legal reform a prerequisite for
progress in health care. Insight 1993 March
29:18-9.

8. Thomas C. Heed the lesson of Sweden.
Wheeling News Register 1993 July 4:9.

SEPTEMBER 1994, VOL. 90 363

Scientific Newsfront

West Virginia Physicians: Cardiovascular risk
factors, lifestyles and prescribing habits

RONALD GAULT, Ed.D.

RACHEL A. YEATER, Ph.D.

IRMA H. ULLRICH, M.D.

Department of Medicine, Robert C. Byrd
Health Sciences Center of West Virginia
University, Morgantown

Abstract

Physicians educate their patients
by direct teaching and by sending as
a role model Through the use of
questionnaires, we evaluated the
degree to which physicians in West
Virginia participate in these activities.
Tliirty-five percent of the 2,404
licensed physicians in the state
returned completed questionnaires.
Although 90% prescribed appropriate
diets and recommended exercise for
their patients, the physicians who
responded were often less likely to
follow their own advice. Twenty
percent of the male physicians and
13% of the female doctors were obese;
30% had LDL cholesterol levels over
130 mg./dl ; 13% had HDL cholesterol
values of less than 35 mg./dl; and
8% had triglycerides over 250
mg./dl Participation in regular
exercise (30 minutes three times per
week ) was reported by 48% of the
male physicians and 47% of the
female physicians. Eight percent of
the men were smokers, as were 1.9%
of the females. These results suggest
that the role model aspect of patient
education may need to be improved
among some West Virginia
physicians. It is an inexpensive
method of directing attention to
lifestyle in order to decrease
preventable disorders such as
coronary artery disease, obesity,
diabetes, and hypertension.

Introduction

Many medical disorders such as
coronary artery disease, diabetes,
obesity, and hypertension are greatly
influenced by lifestyle factors such as
diet, inactivity, and smoking. In states
like West Virginia, in which these
disorders rank among the highest in
the nation (1), it is particularly

important to direct attention to
preventive lifestyle measures such as
proper nutrition, exercise, and
smoking cessation. These preventive
measures are also much less
expensive than in-hospital care.

Physicians, because of their
different specialties, are involved in
education regarding healthy lifestyles
to varying degrees. Although in some
medical specialties such as pathology,
physicians may have little opportunity
for educating patients directly, they
may still serve as examples in the
community for appropriate behaviors.
This is especially true in a rural area
where the physician may be a leader
in the community.

Several recent studies have shown
that medical students and physicians
are not living healthy lifestyles
themselves. At the West Virginia
University School of Medicine,
research has shown that many second-
year medical students were at
increased risk of developing
cardiovascular disease due to inactivity,
hypertension, hyperlipidemia, and
stress (2). At Temple University
Medical Center, a questionnaire
revealed that physician behaviors with
respect to preventive health practices
such as alcohol use, sleep, exercise,
smoking, and obesity were not
substantially different from those of
the general population (3). In addition,
a study of physical activity among
physicians in Saskatoon,

Saskatchewan determined that of the
210 physicians responding to a
questionnaire, only 30% were
considered to be physically active (4).
This was less than the general Canadian
population. These physicians did,
however, believe that exercise was
important to them personally and that
patients should be informed of the
benefits of physical activity.

In an editorial concerning
physicians, Shangold (5) remarked
that “The medical profession has
created a large credibility gap with the
general population by the failure of its
members to practice what they preach.”
In a position statement regarding
physical activity for all Americans,

Fletcher and colleagues (6) stated
“Physicians have the opportunity and
responsibility to promote regular
exercise as well as the reduction of
high blood pressure, management of
abnormal blood lipids, and prevention
and cessation of smoking.”

Physicians have a dual role in
promoting lifestyle changes among
their patients by serving as both role
models and educators. Since the
degree to which these roles are
practiced by West Virginia physicians
was unknown, we decided to examine
the following two questions:

1) The incidence rates in West
Virginia physicians for several
heart disease risk factors; and

2) The frequency with which these
physicians counseled their patients
regarding diet and exercise.

Methods

A questionnaire was designed to
evaluate various risk factors for
coronary artery disease and the
prescribing habits of physicians. This
survey and a cover letter explaining its
purpose were mailed to all physicians
who were members of the West Virginia
State Medical Association residing in
West Virginia. Another mailing was
sent six weeks later to the physicians
who had not responded initially. Of
the 2,404 available subjects, 834 (35%)
returned completed questionnaires.

The questionnaire requested
information concerning height,
weight, blood pressure, blood lipid
values, smoking, diabetes, and
personal and family history of heart
disease. Leisure time physical activity
was categorized into moderate activity
such as brisk walking, hard activity
such as half-court basketball or
scrubbing floors, and very hard
activity (shoveling snow or running).
Subjects were asked to indicate their
level of stress on a scale of 1 to 10,
with 1 being no stress and 10
indicating severe stress. Work and
leisure time stress levels were rated.

Patient education was evaluated
with a question which asked about
the prescription of exercise to

364 THE WEST VIRGINIA MEDICAL JOURNAL

Table 1. Personal Health Characteristics of the Male and Female Physicians Surveyed

Internal

Medicine

Family

Practice

Surgerv

Pediatrics

Other

Age

49±15*

51±16

51±13

48±15

49+13

Body Mass Index

24±4

25+4

24±5

24±4

Resting Blood Pressure (mmHg)

120/75

125/78

122/76

120/74

120/75

Cholesterol, Total (mg./dl.)

192

193

194

191

193

Cholesterol, HDL (mg./dl.)

Cholesterol, LDL (mg./dl.)

124

127

118

125

124

Triglycerides (mg/dl)

131

135

137

102

163

Work Stress

6.1

6.2

Leisure Time Stress

3.3

3.4

3.3

3.4

3.1

* Mean Values

Table 2. The Female Physicians’ Rates of Heart Disease, Smoking, Diabetes and Exercise

Specialties

Internal

Medicine

Family

Practice

Surgerv

Pediatrics

Other

Number

Known Heart Disease

Yes

21 (100%)

1 (6%)
15 (94%)

2 (10%)
19 (90%)

2 (10%)
17 (90%)

3 (10%)
26 (90%)

Using Antihypertensives

Yes

22 (100%)

2 (12%)
14 (88%)

21 (100%)

2 (10%)
18 (90%)

2 (7%)
27 (93%)

Smokers

Yes

22 (100%)

16 (100%)

21 (100%)

1 (5%)
19 (95%)

1 (3%)
28 (97%)

Diabetes

Yes

22 (100%)

16 (100%)

21 (100%)

1 (5%)
19 (95%)

29 (100%)

Exercise

Yes

10 (45%)
12 (55%)

6 (37%)
10 (63%)

12 (57%)
9 (43%)

10 (50%)
10 (50%)

13 (45%)
16 (55%)

Table 3- The Male Physicians’ Rates of Heart Disease, Smoking, Diabetes and Exercise

Specialties

Internal

Medicine

Family

Practice

Surgery

Pediatrics

Other

Number

186

139

204

163

Known Heart Disease

Yes

21 (11%)
163 (89%)

23 (16%)
116 (84%)

23 (12%)
174 (88%)

2 (6%)
31 (94%)

23 (14%)
139 (86%)

Using Antihypertensives

Yes

21 (11%)
162 (89%)

23 (16%)
116 (84%)

35 (17%)
165 (83%)

3 (9%)
31 (91%)

25 (15%)
136 (85%)

Smokers

Yes

11 (6%)
174 (94%)

10 (7%)
129 (93%)

23 (11%)
179 (89%)

4 (12%)
30 (88%)

10 (6%)
153 (94%)

Diabetes

Yes

6 (3%)
178 (97%)

4 (3%)
135 (97%)

3 (2%)
199 (98%)

1 (3%)
32 (97%)

8 (5%)
155 (95%)

Exercise

Yes

93 (51%)
90 (49%)

60 (43%)
79 (57%)

101 (51%)
98 (49%)

10 (29%)
24 (71%)

79 (49%)
82 (51%)

patients. Another question asked
whether nutritional counseling was
provided “always,” “sometimes,” or
“never.” Data was analyzed according
to gender and the following medical
specialties: internal medicine, family
practice, surgery, pediatrics, and
other. The individuals who practiced
pathology, psychiatry, radiology,
anesthesiology, and all other
specialties not included in the first
four groups were included as other.

Results

There were 208 physicians (23.9%)
classified as internal medicine specialists,
155 (17.8%) as family practitioners,

225 (25.8%) as surgeons, 54 (6.2%) as
pediatricians, and 192 (22%) as other
specialists. The mean age of the
respondents was 50 years with no
differences among specialties; 12.9%
were women. Overall, 86.4% of the
physicians surveyed reported they were
currently married; 84.4% were
Caucasian.

Several characteristics of the
physicians are listed in Table 1. The
body mass index (weight in kilograms
+■ height2 in meters) is a measure of
body fatness. The mean BMI was in a
desirable range for all groups, but 20%
of the males and 13% of the females
were obese. Reported mean resting
blood pressure was well within the
normal range, although, some
physicians were taking antihypertensive
medications (Tables 2,3).

Mean lipid values (total cholesterol,
LDL and HDL cholesterol, and
triglycerides) for all specialty' groups
were within the range recommended by
the National Committee for Cholesterol
Education Program (7). However, 30%
had LDL cholesterol levels over 130
mg./dl., 13% had HDL cholesterol
levels less than 35 mg./dl., and 8%
had triglycerides over 250 mg./dl.

As expected, less stress was noted
in leisure times compared to work
with little difference noted among
specialties or gender. Thirteen percent
of the male physicians reported
existing heart disease, while only 7.5%
of the female physicians reported it.
More males (15%) than females (6%)
used antihypertensive medicines.
Tables 2 and 3 list other characteristics
by gender and specialty. Eight percent
of the male physicians and 1.9 percent
of the female physicians were
smokers; pediatricians were more
likely to be smokers than other
specialists.

Diabetes was present in 3% of the
male physicians and 68% of these
individuals had non-insulin dependent

diabetes. One female physician
reported type II diabetes.

Men reported regular exercise (a
minimum of 30 minutes per session,
three times weekly) 48% of the time
as compared to 47% of the women.
Male pediatricians and female family

practitioners were the least likely to
participate in regular exercise.

Table 4 lists answers to questions
regarding prescription of exercise and
provision of nutrition counseling. More
than 90 percent of both male and
female physicians prescribed exercise

SEPTEMBER 1994, VOL. 90 365

either always or sometimes. Likewise,
90% of all physicians reported that
they provided nutritional counseling
either always or sometimes.

Discussion

Physician behavior can make as
important a contribution to patient
education about a healthy lifestyle as
does what is taught directly. This
study has examined by questionnaire
the behavior of West Virginia
physicians. Although over 90% of
responding physicians said they
prescribed both exercise and proper
nutrition to their patients, they were
less diligent in following their own
advice. Less than half of those
surveyed exercised the recommended
30 minutes three times weekly. Twenty
percent of the male and 13% of the
female physicians were obese. Several
physicians were smokers.

The incidence of existing heart
disease of only 13% in the men and
7.5% in the women, may reflect their
higher socio-economic status. This has
been reported previously in a large
group of male physicians who
participated in the Physicians’ Health
Study (8). The relatively young age (a
mean of 50 years) of the respondents
may also be important.

Diabetes and hypertension are
important risk factors for coronary
artery disease which may also be
modified by diet and exercise. Diabetes
was reported in only three percent of
the physicians in our studies. It is not
known whether all of those with type
II diabetes were obese. Epidemiologic
studies (9) have shown that
hypertension, obesity, and inactivity,
as well as a positive family history are
important predictors of diabetes.
Conversely, even in those with a
positive family history, avoidance of
obesity and performance of routine
exercise may prevent diabetes. These
factors may be especially important in
West Virginia which has one of the
highest rates of diabetes in the United
States.

Hypertension was present in up to
15% of the male physicians and is
likely multifactorial in origin. It should
be recalled that exercise may serve as
both prevention as well as therapy for
hypertension (TO).

Many medical schools, including
those in West Virginia, have only
recently added nutrition education to
their curriculum. Family practice
residences have required such
education since 1983 (11), but many
of the physicians we surveyed would

Table 4. The Tendencies of Both Male and Female Physicians to Prescribe Exercise and
Provide Nutritional Counseling

MALES

Internal

Medicine

Family

Practice

Surgerv

Pediatrics

Other

Prescribe Exercise
Always
Sometimes
Never

69 (40%)
95 (55%)
10 (6%)

53 (42%)
74 (58%)

59 (32%)
115 (62%)
12 (7%)

9 (28%)
21 (66%)
2 (6%)

27 (24%)
70 (61%)
18 (16%)

Provide Nutritional
Counseling
Always
Sometimes
Never

58 (34%)
107 (62%)
8 (5%)

37 (29%)
89 (71%)

24 (13%)
137 (73%)
26 (14%)

8 (25%)
23 (72%)
1 (3%)

12 (10%)
74 (64%)
29 (25%)

FEMALES
Prescribe Exercise
Always
Sometimes
Never

13 (59%)
8 (36%)
1 (5%)

10 (67%)
5 (33%)

5 (24%)
14 (67%)
2 (10%)

7 (37%)
12 (63%)

8 (42%)
6 (32%)
5 (26%)

Provide Nutritional
Counseling
Always
Sometimes
Never

9 (41%)
12 (55%)
1 (5%)

8 (53%)
7 (47%)

7 (33%)
11 (52%)
3 (14%)

7 (37%)
12 (63%)

5 (26%)
9 (47%)
5 (26%)

have completed their formal training
prior to this time. There continues to
be a lack of instruction on the
appropriate use of exercise as a
therapeutic modality. Because of an
initial increase in mortality with heavy
exertion (12), caution must be used
when prescribing exercise to a
sedentary individual.

The response rate of 35%, while
better than the 10% response to most
questionnaires, is a major limitation of
our study. The relatively small numbers
in some specialties such as pediatrics,
makes observations less reliable.
Women physicians represented only
13% of the total responders which
may underrepresent their total
involvement in the care of West
Virginians. Some specialists have
limited contact with patients, therefore,
the questions relating to giving advice
to patients has little meaning.

It appears from the results of this
survey that West Virginia physicians
are active in giving nutritional advice
and prescribing exercise to their
patients. However, there is room for
improvement in the role model aspect
of physician behavior. Those physicians
who are smokers would be best
advised to discontinue this habit for
their own health as well as to
enhance their credibility as health
experts. Those physicians who are
obese and sedentary may be less than
convincing to their patients when they
give advise on diet and exercise. The
role model aspect of patient education
is inexpensive and may be particularly
important in a rural community.

References

1 . West Virginia Department of Health and
Human Resources; Bureau of Public Health
Office of Epidemiology and Health
Promotion. Heart Disease and Stroke:
Cardiovascular Disease in West Virginia.

Nov 1993.

2. Troyer D, Ullrich IH, Yeater RA, Hopewell R.
Physical activity and condition, dietary
habits and serum lipids in second-year
medical students. J Am Coll Nutr 1990;
9:303-7.

3. Glanz K, Fiel SB, Walker LR, Levy MR.
Preventive health behavior of physicians. J
Med Educ 1982;57:637-9.

4. Gaertner P, Firor W, Edouard L. Physical
inactivity among physicians. J Med Educ
1991;144:1253-7.

5. Shangold M. The health care of physicians:
Do as I say and not as I do. J Med Educ 1979;
54:668.

6. Fletcher GF, Blair S, Blumenthal J.

Statement on exercise: benefits and
recommendations for physical activity
programs for all Americans. Circulation
1992;86:2726-30.

7. National Cholesterol Education Program.
Second Report of the Expert Panel on
Detection, Evaluation and Treatment of
High Blood Cholesterol in Adults. Executive
Summary. Nat Inst of Health, GCS July 1993-

8. The Steering Committee of the Physicians’
Health Study Research Group. Preliminary
Report; Findings from the Aspirin Component
of the Ongoing Physicians’ Health Study. N
Engl J Med 1988;381:262-4.

9. Helmrich SP, Ragland DR, Leung RW,
Paffenbarger RS. Physical activity and reduced
occurrence of non-insulin-dependent diabetes
mellitus. N Engl J Med 1991;325:147-52.

10. Yeater RA, Ullrich IH. Hypertension and
exercise. Postgrad Med 1992;91:429-36.

11. Geyman JP. Nutrition teaching in medical
education: a case of chronic neglect. J Fam
Pract 1984;18:193-4.

12. Mittleman MA, Maclure M, Tofler GH,
Sherwood (B, Goldberg RJ, Muller JE.
Triggering of acute myocardial infarction by
heavy physical exertion. Protection against
triggering by regular exertion. N Eng J Med
1993;329:1677-83.

366 THE WEST VIRGINIA MEDICAL JOURNAL

A study of helicobacter-pylori in 100 pediatric
patients from the Tri-State area

DEBORAH M. LOPEZ, M.D.

YORAM ELITSUR, M.D.

Division of Pediatric Gastroenterology,

Department of Pediatrics, Marshall University

School of Medicine, Huntington
—

Abstract

Helicobacter pylori (HP) is a
newly discovered pathogen
implicated in the pathophysiology of
peptic ulcer disease. The aim of this
study was to review all pediatric
patients who were evaluated by
upper endoscopy through the
Pediatric Gastroenterology Service
at the Marshall University School of
Medicine between July 1990 and
March 1993 ■ A total of 100 charts
were retrospectively reviewed HP
was diagnosed by CLO-test and
confirmed histologically. Results
showed that the major presenting
symptom was abdominal pain ( 53% ).
G1 mucosal inflammation was found
in 77 patients, and 41% of these cases
were associated with HP. Two
patients had duodenal ulcer; both
were HP+. The incidence of gastritis
was significantly higher in patients
with HP+ compared to HP-. Follow-up
on the HP-associated gastritis
showed no significant difference in
their clinical response irrespective
to the treatment, we conclude that
HP in children is highly associated
with gastritis, but not duodenitis or
esophagitis; and in our experience,
that CLO has a high failure rate in
identifying HP in the mucosa.

Introduction

Helicobacter pylori (HP), a gram-
negative, motile, spiral-shaped
bacterium was discovered in 1983 by
Warren and Marshall (1). HP has been
recently recognized as the most
prevalent cause of chronic gastritis in
adults (2,3) and children (4,5). Studies
have also demonstrated that almost all
primary duodenal ulcer disease is
related to HP (3,5).

The prevalence of HP infection
among asymptomatic adults and
children has been shown to increase
with age (6,7,8). In adults, HP has
been associated with approximately
92% of duodenal ulcers and 70% of
gastric ulcers (9,10). In children, the
presence of HP is associated with

gastritis (11,12) and possibly with
duodenal ulcer (13,14). Although data
on HP in children is limited, it is
suggested that the incidence of HP in
the pediatric population is lower than
that seen in the adult population (4,5).

In this study, we report our clinical
experiences with HP in 100 pediatric
patients who underwent endoscopy
between July 1990 and March 1993 by
the Pediatric Gastroenterology Service
at the Marshall University School of
Medicine.

Materials and methods

The charts of all children who
underwent endoscopy between July
1990 and March 1993 by the Pediatric
Gastroenterology Service at the
Marshall University School of Medicine
were reviewed for demographic,
clinical and histological data. The
patients were retrospectively divided
into two groups according to their
antral biopsy results: HP positive
(Group A) and HP negative (Group B)
patients.

Pediatric endoscopes, Olympus GIF
XP 10 or XP 20, were used in all
patients. Three to four biopsies from
the stomach (antrum) and the
duodenum were taken for routine
histological examination and for
Giemsa stain. In each endoscopy, an
antral biopsy was also taken for rapid
urease test (CLO-test). CLO-test was

warmed to body temperature before
each endoscopy. The initial reading
was done at approximately 20 minutes
after endoscopy, and the final results
were read at 24 hours.

Results

A total of 100 children who
complained of various abdominal
symptoms between July 1990 and
March 1993 had an upper endoscopy
as part of their medical evaluation. Ages
ranged from 3 months to 20 years with
a median age of 10 years. There was a
total of 60 male and 40 female patients
(male/female ratio 1.5). Group A had
a median age of 7 years and a
male/female ratio of 1.0, and Group
B’s median age and male/female ratio
was 9 years and 1.5, respectively.

The most common presenting
symptoms in both groups were
abdominal pain and vomiting. Overall,
there were no statistically significant
differences observed in the presenting
symptoms between both groups
(Table 1). The rate of esophagitis was
similar in both groups. The incidence
of gastritis was significantly higher (up
to 10 times) in patients from Group A
compared to patients in Group B.
Patients in Group A had a higher
duodenitis rate and more severe disease
compared to Group B, but those
differences did not reach significance.
Two patients in Group A were

TABLE 1. Presenting Symptoms

Group A

Grouo B

Number of Patients

Abdominal Pain

15 (57%)

39 (52%)

Vomiting

10 (38%)

20 (27%)

Chest Pain

2 (7%)

8 (10%)

FTT

1 (4%)

7 (9%)

Weight Loss

1 (4%)

3 (4%)

Hematemesis

2 (8%)

4 (5%)

TABLE 2. Histological Results

Group A

Group B

POSITIVE

NEGATIVE

Esophagitis

15/26 (57%)

38/74

(51%)

Gastritis

14/26 (54%)*

4/74

(5%)

Duodenitis

3/26 (11%)

4/74

(5%)

Mild

0 (0%)

(100%)

Moderate

1 (33%)

(0%)

Severe

2 (67%)

(0%)

Peptic Ulcer

2/26 (8%)

0/74

(0%)

*p<0.05

SEPTEMBER 1994, VOL. 90 367

TABLE 3. CLO-Test Results

Group A

Group B

CLO Positive

5/26 (19%)

2/74 (3%)

CLO Negative

21/26 (81%)

72/74 (97%)

TABLE 4. Treatment and Follow-up of Symptomatic Patients with HP

Treatment Groups

H2 Alone

H2+AB+BS*

AB Alone

No Treatment

Number

Histology

Gastritis

3/6

5/6

2/2

4/9

Esophagitis

5/6

1/2

3/9

Duodenitis

1/6

2/6**

0/2

0/9

Follow-Up

Months (mean)

3.4

4.0

4.6

Symptoms Resolved

5/6

4/6

1/2

8/9

*H2 - H2 blocker (Zantac) *AB - antibiotic (amoxicillin/metronidazole)

*BS - Bismuth subsalicylate "2 patients with duodenal ulcer

diagnosed with peptic ulcer disease
(Table 2). Rapid urease enzyme
detection (CLO-test) identified only
19% of histologically confirmed HP
patients (Table 3).

The treatment and clinical responses
of the patients who were histologically
diagnosed with HP are presented in
(Table 4). Out of the 26 HP+ patients,
six were treated with HI -blocker
alone, two with antibiotic alone, six
with H2-blocker and anti-HP
medications (Pepto-Bismol +
amoxycillin), and nine were not
treated with any of these medications.
The two patients diagnosed with active
duodenal ulcer were treated with H2-
blocker and anti-HP medication.

Three patients were lost to follow-up,
but the remaining results showed that
the vast majority (78%) of our patients
had resolved their symptoms after up
to 4.6 months follow-up, regardless of
the treatment. There was also no
difference in the severity of gastritis
between the groups.

Discussion

Since the discovery of HP in 1983
by Warren and Marshall (1), its
distribution in Western society has
been well documented. The prevalence
of HP in symptomatic children has
been estimated between 10 percent to
30 percent, and has an inverse
correlation to socioeconomic status
(15). Similar to adults, the incidence
of HP in children increases with age
(8,16,17,18).

Although the knowledge on HP
increased significantly over the last
decade, there is no data available on
HP prevalence and its clinical
presentation in children of West
Virginia. The incidence of HP in our
patient population was up to 30
percent. This figure is consistent with
previous reports. As earlier observed

(19) , we also did not find significant
differences in the clinical symptoms
between patients who were HP
positive or negative (Table 1). This
may suggest that further laboratory
evaluation is indicated in patients
presenting with similar symptoms to
exclude HP.

CLO-test is a rapid ureas test widely
accepted as a quick method to
diagnose HP during endoscopy.
Several studies reported that CLO-test
specificity and sensitivity is > 90%

(20) . The manufacturer’s instruction
for the use of CLO-test indicates that
best results may be achieved when
CLO-test is at 37°C before embedding
the biopsies into the culture medium,
and that final reading should be done

after 24 hours. We carefully followed
the manufacturer’s instruction, but
were able to detect only 15% of all
biopsies which subsequently were
confirmed histologically with HP.

The poor correlation between CLO-
test and Giemsa stain may suggest
that the number of HP bacterium
and/or the amount of ammonia
production may affect CLO-test
positivity. Whether these factors are
the reason for our high CLO-test false
negativity rate is yet to be determined.
We concluded that the clinical value
of CLO-test in our practice is limited.

The current recommended
treatment for HP-associated peptic
ulcer disease is H2-blocker with anti-
HP medications including antibiotic
(amoxycillin and/or metronidazole)
and bismute salts (Pepto-Bismol).
Previous data in children showed that
this protocol is advantageous for
healing peptic ulcers compared to H2-
blocker alone (21). We are not aware
of any double-blind, cross-over,
controlled studies evaluating the
efficacy of medical treatment (placebo
vs. H2-blocker with or without anti-
HP medication) in children with HP-
associated gastritis without ulceration.

Drumm and colleagues (22) have
shown clear associations between HP
and histological gastritis in children.
This same group (23) has also shown
that eradication of HP with medical
treatment resulted in resolution of
symptoms. Although this study may
suggest that such treatment is
indicated in children with HP-
associated gastritis, their study did not
contain a control group. We did not
find any significant clinical advantage
for either treatment for patients with

HP-associated gastritis without
ulceration. Since our patient
population was small with a short
follow-up period, we cannot draw any
firm conclusions. We speculate that
since true ulceration in the pediatric
population is the exception rather
than the rule, further controlled
studies to solve this dilemma of
whether to treat or not are clearly
warranted.

In conclusion, this is the first report
of HP in children of West Virginia. We
demonstrated that HP is common in
our patient population and that the
diagnosis cannot be obtained on
clinical ground only. Although
medical treatment is recommended in
symptomatic patients with HP-
associated gastritis, we found
symptomatic resolution irrespective of
treatment regimen. We conclude that
controlled studies to evaluate this
dilemma are warranted.

Acknowledgements

The authors wish to thank Jennifer
Long for her excellent secretarial
assistance.

References

1. Warren JR, Marshall BJ. Unidentified curved
bacilli on gastric epithelium in active chronic
gastritis. Lancet 1983;i:1273-5.

2. Blaser MJ. Gastric Campylobacter-like
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3. Graham DY. Campylobacter pyloridis and
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4. Czinn SJ, Dahms BB, Jacobs GH, et al
Campylobacter-like organisms in association
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5. Hassall E, Dimmick JE. Unique features of
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368 THE WEST VIRGINIA MEDICAL JOURNAL

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Effect of age on the frequency of active
Campylobacter pylori infection diagnosed
by the urea breath test in normal subjects
and patients with peptic ulcer disease. J
Infect Dis 1988;157:777-80.

7. Pettross CW, Appleman MD, Cohen H, et al.
Prevalence of Campylobacter pylori and
association with antral mucosal histology in
subjects with and without upper
gastrointestinal symptoms. Dig Dis Sci 1988;
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8. Morris A, Nicholson G, Lloyd G, et al.
Seroepidemiology of Campylobacter
pyloridis. NZ MedJ 1986;99:657-9.

9- Marshall B, Warren JR. Unidentified curved
bacilli in the stomach of patients with
gastritis and peptic ulceration. Lancet
1984;i: 131 1-4.

10. Price AB, Levi J. Dolby JM et al.

Campylobacter pyloridis in peptic ulcer
disease. Microbiology, pathology and
scanning electron microscopy. Guy 1985;26:

1 183-8.

11. Drumm B, Sherman P, Cutz E, et al.
Association of Campylobacter pylori on the
gastric mucosa with antral gastritis in
children. N Engl J Med 1987;316:1557-61.

12. Drumm B, O'Brien A, Cutz E, et al.
Campylobacter pyloridis associated primary
gastritis in children. Pediatrics 1987;180:192-5.

13. Killbridge PM, Dahlms BB, Czinn SJ.
Campylobacter pylori associated gastritis
and peptic ulcer disease in children. Am J
Dis Child 1988;142:1149-52.

14. Queiroz DMM, Rocha GA, Mendes EN, et al.
Differences in distribution and severity of
Helicobacter pylori gastritis in children and
adults with duodenal ulcer disease. J
Pediatr Gastroenterol Nutr 1991;12:178-81.

15. Drumm B. Helicobacter pylori. Arch Dis
Child 1990;65:1278-82.

16. Graham DY, Klein PD. Campylobacter
pyloridis gastritis: the past, the present and
speculations about the future. Am J
Gastroenterol 1987;82:283-6.

17. Perez-Perez GI, Dworkin BM, Chodos JE, et
al. Campylobacter pylori antibodies in
humans. Ann Intern Med 1988;109:11-7.

18. Kosunen TUP, Hook J, Rautelin HI, et al.
Age-dependent increase of Campylobacter
pylori antibodies in blood donors. Scand J
Gastroenterol 1989;24:110-4.

19. Ashorn M, Maki M, Ruuska T, et al. Upper
gastrointestinal endoscopy in recurrent
abdominal pain of childhood. J Pediatr
Gastroenterol Nutr 1993;16:273-7.

20. Oderda G, Vaira D, Holton J, et al.

Helicobacter pylori in children with peptic
ulcer and their families. Dig Dis Sci 1991;
36:572-6.

21 Israel D, Hassall E. Treatment and long-term
follow-up of Helicobacter pylori-associated
duodenal ulcer disease in children. J Pediatr
1993;123:5-58.

22. Drumm B, Sherman P, Cirtz E, et al.
Association of Campylobacter pylori on the
gastric mucosa with antral gastritis in children.
N Engl J Med 1987;(June 18):1557-6l.

23. Drumm B, Sherman P, Chiasson D, et al.
Treatment of Campylobacter pylori-
associated antral gastritic in children with
bismuth subsalicylate and ampicillin. J
Pediatr 1988;113:908-12.

Ninth Annual Trauma Conference - Rural Trauma
September 30 - October 1, 1994

Glade Springs Resort and Conference Center
near Beckley, West Virginia

For more information, please contact Continuing Education and Conference Services, (304) 348-9581 .

Charleston Area
Medical Center

SEPTEMBER 1994, VOL. 90 369

A combined internal medicine-psychiatry clinic
at a community hospital: Initial experiences

JAMES P. GRIFFITH, M.D.

Assistant Professor of Internal Medicine and
Psychiatry, Robert C. Byrd Health Sciences
Center of West Virginia University, Charleston
Division; Charleston Area Medical Center,
Charleston

Abstract

A new internal medicine/psychiatry
outpatient clinic was recently
established at Charleston Area
Medical Center (CAMC). Tljis report
describes the clinical profiles of the
first 52 patients and also reviews
the clinic’s staffing, facilities, referral
sources and reimbursement. For
large community hospitals, a med-
psych clinic may be a useful method
of providing psychiatric treatment
to medically-ill outpatients.

Introduction

A variety of factors have contributed
to an increased interest in combined
medical-psychiatric treatment programs.
From a clinical standpoint, several
patient groups might benefit from such
an approach (i.e. patients with
concurrent medical and psychiatric
illness, somatic patients, “organic”
psychiatric patients, patients who
refuse treatment in traditional psychiatric
settings, etc...). Opportunities also
exist for educational and research
activities within a structured setting
that provides combined medical and
psychiatric treatment.

There are several reports in the
literature of clinics designed to provide
combined medical and psychiatric
treatment. These have been labeled as
“consultation liaison” clinics (1-4),
“psychosomatic” clinics (5-6), “special
medicine” clinics (7), “medicine/
psychiatric clinics” and others (8-14).

This report describes the
Multispecialty Clinic at CAMC and
reviews data from the first 16 months
of the clinic’s operation.

The Multispecialty Clinic

The clinic opened in October 1990
with several objectives. Clinical
objectives were primarily to provide
outpatient psychiatric follow-up to the
consultation liaison service, and to
provide accessible psychiatric services
to the other hospital clinics. Training
objectives were to provide education

to psychiatry residents, internal medicine
residents, combined internal medicine/
psychiatry residents, psychology
interns and medical students in the area
of medical psychiatry. In addition, the
clinic also was established to provide a
patient base for much needed research
in the combined med-psych area.

The clinic was located in one of the
areas at CAMC also used for other
hospital clinics (i.e. medical, surgical,
etc...). Only minor renovations
allowed the space to be appropriate
for medical psychiatric treatment as
well. The clinic was conducted one
morning each week and was staffed
by the medical director (an internist/
psychiatrist), a nurse, and a receptionist
who registered patients for many
clinics simultaneously. Psychiatry,
internal medicine, med/psych
residents, doctoral level psychology
interns and medical students also
participated in the clinic.

Clinical information

During the first 16 months of
operation, a total of 79 new patient
evaluations were scheduled, of whom
52 (67.1%) actually arrived. Compliance
with scheduled follow-up appointments
was 87.8% (192/230). The internal
medicine clinic and inpatient
psychiatric unit provided the largest
number of referrals (Table 1).

Patients referred to the clinic from
the consult-liaison service were the
least likely to keep their initial
appointment (Table 2). Demographic
and clinical data regarding these first
52 patients is summarized in Tables 3-
5. Females slightly outnumbered
males and a wide range of ages were
seen in the clinic. Cardiovascular and
neurologic conditions were the most
frequent medical problems; affective,
anxiety and organic mental disorders
were the most frequent psychiatric
diagnoses.

Medical and psychiatric diagnoses
among patients from specific referral
sources are summarized in Tables 6-7.
No statistically significant differences
were present among this small
number of patients. The inpatient
psychiatric unit tended to refer
patients with comorbid cardiac or
neurologic disorders. Predictably,
neurologists tended to refer those with
organic mental illnesses attributable to
their neurologic problems (i.e.

cerebrovascular disease).

Medical/psychiatric comorbidity is
summarized in (Table 8). As noted,
mood and anxiety disorders were
quite prevalent among those patients
with cardiac and gastrointestinal
disorders. Organic syndromes were
seen quite often among those with
neurologic illnesses.

Reimbursement information is
summarized in Table 9-

Discussion

Patients with medical and
psychiatric comorbidity continue to be
a challenge to manage in traditional
settings. Our new med-psych clinic
received referrals from a variety of
sources. The referral pattern likely
reflected the proximity of the clinic to
the medical clinic, and also familiarity
with the clinic by the inpatient
psychiatric service since the facility was
not advertised in the local community.

Table 1. Med-Psych Clinic Referral
Sources (N=52)

N %

Med Clinic

28.8

Inpatient Psychiatric Unit

21.1

Neurologist/Neurosurgeon

9.6

Cardiologist

7.7

Consultation/Liaison

7.7

Internist/GP/FP

5.8

Psychiatrist

5.8

Surgery Clinic

3.8

Med Rehab

3.9

Clinics (Other)

3.8

Gastroenterologist

1.9

Table 2. No Show Rate (Initial

Appointment) According to
Referral Service

Medicine Clinic

1/16

6.2%

Surgery Clinic

1/3

33%

Internist/GP/FP

0/3

Cardiology

1/5

20%

Inpatient Psychiatry

7/18

38%

Consult/Liaison

7/11

63%

Table 3- Age and Sex of Med-Psych
Clinic Patients (N=52)

N Avg. Age (yrs)

Male 23 (44%) 49.2 (range 17-83)

Female 29 (56%) 42/1 (range 23-62)

370 THE WEST VIRGINIA MEDICAL JOURNAL

An early trend indicated a low rate
(37%) of keeping appointments
among patients referred from the
consultation-liaison service. This may
be due to the fact that these patients
are ambivalent about psychiatric
treatment as previously noted (2). In
addition, the pattern of medical and
psychiatric illnesses among referred
patients may be the result of many
possible factors. The most frequent
diagnoses may simply reflect disease
prevalence among the population, the
referring physician’s practice or the
types of patients treated at our hospital.
Referring physicians may have been
better able to recognize certain
psychopathology or perhaps felt least
comfortable managing the types of
patients referred.

A high prevalence of mood and
anxiety disorders was present in
patients with cardiac and gastrointestinal
ailments. These associations have been
previously noted (15-17), and may
simply be a coincidence due to the
high prevalence of all of these disorders,
emotional reactions to physical
illnesses, or some yet to be defined
factors linking these diseases. The staff s
initial experiences at this med-psych
clinic have been favorable. Compliance
with follow-up appointments has
been good, and our reimbursement
rates have been excellent. There is
obviously a need for such services
since patients have been referred from
many areas of the medical center.

As patients continue to live longer
with complex medical and psychiatric
problems, community' hospitals may be
able to more effectively manage these
patients with a med-psych clinic model.

Acknowledgements

The author expresses his appreciation
to Ms. Jodi Asbury for her clerical
assistance with this manuscript.

References

1. Kaplan KH. Development of a psychiatric
liaison clinic. Psychosomatics 1981;2:502-12.

2. Rowan GE, Strain JJ, Gise LH. The liaison
clinic: A model for liaison psychiatry
funding, training and research. Gen Hosp
Psychiatry 1984;6:109-15.

3. Schwartz J, Speed N, Kuskowski N. A
psychiatry consultation-liaison clinic:
Follow-up of 54 patients referred from
neurology. Int J Psychiatry Med
1987;17:213-21.

4. Camara EG. A psychiatry outpatient
consultation-liaison clinic. Experience at the
Cleveland Clinic Foundation. Psychosomatics
1991;32(3):304-8.

5. Fava GA, Trombini G, Grandi S, Bemadi M,
Canestrari R. A psychosomatic outpatient
clinic. Int J Psychiatry Med 1987;17:261-7.

Table 4. Medical Diagnoses of Med-Psych Clinic Patients (N=52)

1 . Cardiovascular Disease

- Coronary Disease

- Hypertension

- Congestive Heart Failure

2. Neurologic Disease

- Seizure Disorder

- Cerebrovascular Disease

- Head Injury

- Congenital/Other

3. Gastrointestinal Disease

17.3

- Irritable Bowel

- Inflammatory Bowel Disease

- Peptic Ulcer Disease

4. Endocrine Disorders

15.4

- Diabetes Mellitus

- Thyroid Disorders

5. Other Medical Illnesses

11.5

6. No Medical Illness

11.5

Table 5. Psychiatric Diagnoses of Med-Psych Clinic Patients (N=52)

1. Affective Disorders

53.8

2. Anxiety Disorders

32.7

3. Organic Disorders

23.0

4. Somatoform Disorders

13.5

5. Personality Disorders

23.0

6. Substance Abuse Disorders
* Some patients have more than one diagnosis.

Table 6. Medical Diagnoses of Med-Psych Clinic Patients From Specific Referral Sources

Medical Clinic
(N=15)

Psychiatry

(N=18)

Neurology
(N= 5)

Internal Medicine
(N=8)

Cardiac

Endocrine

Gastrointestinal

Neurologic

Other

None

Table 7. Psychiatric Diagnoses of Med-Psych Clinic Patients From Specific Referral Sources

Medical Clinic
(N=15)

Psychiatry

(N=18)

Neurology
(N= 5)

Internal Medicine
(N=8)

Affective Disorders

Anxiety Disorders

Organic Disorders

Personality Disorders

Somatoform Disorders

Substance Abuse

Table 8. Psychiatric Diagnoses Among Patients With Selected Medical Illnesses

Cardiac

Neurologic

Endocrine

Gastrointestinal

(N=25)

(N=12)

(N= 8)

(N=9)

Affective Disorders

Anxiety Disorders

Substance Abuse

Organic Disorders

Somatoform Disorders

Personality Disorders

SEPTEMBER 1994, VOL. 90 371

Table 9- Payor Mix of Patients in Med-Psych Clinic (N=52) (October 1990 -

March 1992)

3rd Party Insurance

42.3

Medicare

21.5

Medicaid

23.0

Private Pay

13.5

Amount Billed

Amount Collected

Rate

$12,515.00

$10,469.09

84%

6. Greenhill MH, Kilgore SR. Principles of
methodology in teaching the psychiatric
approach to medical house officers.
Psychosom Med 1950;12:38-48.

7. Hossenlopp CM, Holland J. Ambulatory
patients with medical and psychiatric
illness: care in a special medical clinic. Int J
Psychiatry Med 1977;8:1-11.

8. Clarke EK. The role of the psychiatric
department in relation to the pediatric
department in a general hospital. Am J
Psychiatry 1931;88:559-66.

9. Saslow G. An experiment with comprehensive
medicine. Psychosom Med 1948;10:165-75.

10. Hunter H, Lyon JM. Clinic H: Haven for
hypochondriacs. Am Practitioner 1951;2:67-9.

11. Ritro JH, Thompson TL. A 49-year-old clinic
for chronically-ill somatizers. Hosp
Community Psychiatry 1986;37:631-3-

12. Adams WR. The psychiatrist in an ambulatory
clerkship for comprehensive medical care in
a new curriculum. J Med Ed 1958;33:211-20.

13- Kiinsbeck HW, Fregberger H. Follow-up
results from a psychotherapist. Psychosom
1987;48:123-8.

14. Haag A. A psychosomatic consultation-liaison
service in a medical outpatient department:
Experience with a random sample of patients.
Psychother Psychosom 1984;42:205-12.

15. Vasquez-Barquero JL, Arceo JAP, Ochoteco A,
Manrique, JFD. Mental illness and ischemic

heart disease: Analysis of psychiatric
morbidity. Gen Hosp Psych 1985;7:15-20.

16. Young SJ, Alpers DH, Norland CC. Psychiatric
illness and the irritable bowel syndrome.
Gastroenterology 1976;70:162-6.

17. Switz DM. What the gastroenterologist does
all day. Gastroenterology 1976;70:1048-50.

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Editor’s Note: The following is Dr.
Burton’s inaugural address which
he delivered on August 20 during
the WVSMA’s Annual Meeting.

Ladies and gentlemen, friends, and
colleagues — I would like to thank
you for the honor of serving as the
president of the West Virginia State
Medical Association for the coming
year. It promises to be a most
interesting time.

Special thanks are in order for, first
of all, my partners of Radiology Inc.,
whose understanding and sacrifice
have made this possible. I don’t think
I could have found a finer group of
physicians to work with. Next, I’d like
to thank my wife, Kathi, whose loving
support is invaluable. And last, but
certainly not least, I’d like to thank my
parents. My father, Russ, passed away
in 1989 at the age of 77. It is in his
memory I dedicate this year. My
mother, Fawn, will be 80 years young
next month and just returned from a
two-week trip to Rome and the Isle of
Capri. Without their guidance, I
wouldn’t be standing here today.

All things change in life. I have
been attending meetings of the West
Virginia State Medical Association,
here, at The Greenbrier, since I was a
young boy in the mid-1960s. I can
remember my father complaining
when the rooms reached an
astronomical $75 a night. It’s hard to
get a good bottle of wine for that
these days. In part, my interest in
medicine stems from those meetings.

At that time, The Greenbrier was
more relaxed with a decidedly “down-
home” atmosphere. I remember the
starter on the Old White course
recalled everyone’s name and

President’s Page

Change and the herding of cats

hometown, and greeted them warmly
on their return. Today, The Greenbrier
is different, it’s larger and more
sophisticated, with international
renown. Yet, it retains the same
impeccable standards of quality and
service while the staff has that same
old “down-home” friendliness.

By the same token, medicine has
profoundly changed in those same
thirty-odd years. Medicare, Medicaid,
Health Maintenance Organizations,
and Diagnostic Related Groups were
all terms absent from the lexicon of
the mid-60s physician. In those days,
no one dared impugn a physician’s
character by calling him a “health
care” provider.

We look upon those times of
simplicity with some longing. At the
same time, physicians practiced
without many of medicine’s modern
tools we take for granted. There were
not CAT Scans, MRIs, calcium channel
blockers, or percutaneous
cholecystectomies. We can clearly see
that change is not necessarily evil for
we still set the standard of medical
practice for the world. We maintain
our standard of excellence with that
“down-home” level of compassion
and caring.

Yet, as future changes loom on the
horizon, I fear that outside
encroachment on the traditional
physician-patient relationship will
damage this standard of care. As Swiss
medical philosopher Ernest Truffer
notes, the increasing interjection of
third parties between doctor and
patient “amounts to a rejection of a
medical ethic which is to care for a
patient according to the latter’s
specific medical requirements in favor
of a veterinary' ethic -- which consists

in caring for the sick animal, not in
accordance with it’s specific medical
needs, but according to the
requirements of its master and owner,
the person responsible for meeting
any costs incurred. I’ll tell you now —

I do not intend to be a “health care
provider,” I am a physician. I do not
intend to practice “veterinary
medicine” — my patients deserve
better.

A crisis exists in health care today.
I’m not talking about the crisis of the
uninsured, of runaway costs or of
over utilization. What I’m talking
about is a crisis of spirit, amongst us,
the physicians. I hardly know a doctor
over 50 who isn’t glad he’s nearer
retirement than not. The physicians of
my generation are profoundly
discouraged. The topic of discussion
typically evolves about their wish to
be in some other profession. It’s sad
to think that bureaucracy, the threat of
malpractice suits, the uncertainty in
our practice, and the disrespect of our
patients and the press has reduced us
to this. My father always preached the
value of an education — something he
said that could never be taken away.
He’d be sad to learn they’re trying to
do just that.

I fear most of all for the welfare of
our patients. The one group most
confused and misled by the rhetoric,
yet most affected by coming changes.
They will be inundated by a vast array
of plans and options; none of which
may suit their needs.

Through it all, there will be a
marked decrease in the level and
sophistication of services. Despite
what is said, rationing will occur; and
choice, for both the patient and the
physician, will be a thing of the past.

374 THE WEST VIRGINIA MEDICAL JOURNAL

Why, I ask you, is this considered
progress?

To my knowledge, we, the
physicians, are the only ones with the
training and education to practice
what truly is the “Art of Medicine.” No
one, not administrators, insurance
executives, managed care
coordinators, and least of all,

Editorial

—

Contemplating

Into an increasingly complex
society, there has come stalking the
medical care delivery giant, sending
the entire population scurrying in all
directions. The politicians, the
lawyers, the lawyer-politicians — are
all at the center of these controversial
discussions as to the best way to
subdue this bumbling giant and make
him subservient to their plans for
society and themselves. As a result,
we’ve been hearing more and more
about the uninsured, the underinsured,
the indigent, the wealthy, Medicare,
Social Security, entitlements, PROs,
balance billing, managed care, pre-
authorizations, cost controls, rural
health, physician shortages and
overages, electronic billing, universal
coverage and on and on.

One is forced to wonder how much
understanding the average person —
indeed the average physician -- has of

government bureaucrats, can make
that claim. Somewhere along the line,
someone, or maybe all of us, should
say “ENOUGH.”

I was once told that getting doctors
to agree is like trying to herd cats.

This year, I intend to do just that.
There is no one in this state that will
be a stronger advocate for your rights,

the complexities

the whole matter. Our political
representatives have been hatching
ideas for monolithic health care
systems for the past many months.

And then someone thought to ask the
General Accounting Office for some
cost estimates. Suddenly some plans
were quietly abandoned by their
authors. For at that point it became
obvious that this kind of a free and
accessible medical care system is tally
the way to bankruptcy.

One of the most disturbing aspects
of the whole controversy is the anxiety
besetting the average office holder
concerning his re-election in the
coming months. A reasonable worry
for the average citizen is that his or
her political representatives might be
panicked into trying to satisfy
shortsighted constituents by passing
some disastrously liberal legislation in
an effort to insure re-election.

no matter what specialty you may
practice, than I. If you’ll support me, I
hope that next year at this time, West
Virginia, a state I love, will be a little
better place for you to practice the art
and science of medicine.

Dennis M. Burton, M.D.

On the brighter side, our medical
organizations have done a tremendous
job of educating some senators and
representatives as to the concern the
medical profession has for its patients,
as evidenced by the proposed Patient
Protection Act, and tax-exempt
Medical Savings Accounts.

It remains to be seen whether or
not the federal government will
manage to bring down the world’s
best system which adequately cares
for at least 85 percent of its
population, in a vain effort to improve
the condition of the remaining 15
percent. No one denies the obligation
of society to care for those least able
to care for themselves. It is equally
clear that not to learn from the failures
of systems of other nations is certainly
inexcusable.

Joe N. Jarrett, M.D.

Associate Editor

SEPTEMBER 1994, VOL. 90 375

Letters to the Editor

The legal responsibility of physicians
supervising physician assistants is significant

The role of physician assistants
within West Virginia has consistently
been expanded since the initial
statutory authority was given enabling
physician assistants to function in
1971. The standards for licensure of
physician assistants have continually
been upgraded, however, the legal
responsibility of the physician
supervising the physician assistant has
remained constant through the years.

The West Virginia Code S30-3- 16( h )
reads “The legal responsibility for any
physician assistant remains with the
supervising physician at all times,
including occasions when the assistant
under his or her direction and
supervision, aids in the care and
treatment of a patient in a health care
facility.” Under the law and regulations,
there must be a person approved by
the West Virginia Board of Medicine
as a supervising physician for a
physician assistant before the
physician assistant may be licensed to
practice as a physician assistant within
the state. The physician assistant is
limited to the performance of those
services for which he or she is trained
and performs only under the
supervision and control of a person
permanently licensed in West Virginia.

A physician assistant may not perform

Some questions

The editorial by Stephen Ward in
the July issue deserves some further
consideration. Hypocrisy in our elected
officials is a major detestation of the
American people, and each episode of
hypocrisy needs to be pointed out.

I believe that it would be wise for
the West Virginia Medical Journal to
write to Senator Rockefeller to request
a copy of his medical record for
evaluation. Some of the more
interesting aspects might be as follows:

1 . Did Senator Rockefeller have a
back problem while he was living
in West Virginia?

any services which his or her
supervising physician is not qualified
to perform.

There must be an established
relationship between physician and
physician assistant before the
physician assistant may function in
West Virginia. The physician assistant
acts as an agent of the supervising
physician at all times. In fact, it is the
physician applying to the West
Virginia Board of Medicine to
supervise a physician assistant (not
the physician assistant) who is
required to provide a job description
to the Board which sets forth the
range of services to be provided by
the physician assistant (West Virginia
Code S30-30-l6(g).

No physician assistant is able to
function legally in this state without a
license from the West Virginia Board
of Medicine, without a Board
approved supervising physician and
without a job description which is
Board approved. Physician assistants
are different from nurse practitioners
in training, national board certification,
and licensure. There are similarities
between these two professions; but
the legal requirements for the two
professions are different.

The legal requirements for and

2. Did he have the diagnosis made by
a generalist or by a specialist?

3. Did he seek treatment in this state
or did he go elsewhere for any
necessary surgery.

And that’s just for starters.

4. We should also request information
as to whether he and his family
would be enrolled in a West Virginia
plan for their future medical care?

5. If he is enrolled in a federal plan in
Washington, will he enjoy any
privileges not accorded to the
plans in West Virginia.

relationship between physicians and
physician assistants is an area not
often understood fully by physicians.
The West Virginia Board of Medicine
has recently again mailed all
physicians in the state the laws and
regulations governing the practice of
physician assistants.

Since the West Virginia Board of
Medicine has jurisdiction over
physicians and physician assistants,
the members of the Board want
practitioners to know what to do to
comply with these requirements and
function properly. For example, no
supervising physician may employ at
any one time more than two physician
assistants. When functioning as a
physician assistant, a physician
assistant must wear a name tag which
identifies himself or herself as a
physician assistant.

We encourage physicians who have
questions to contact the Board offices
at (304) 558-2921 for assistance.

Michael Grome, P.A. -C

Chair, Physician Assistant Committee

West Virginia Board of Medicine

Deborah Lewis Rodecker, J.D.

Counsel

West Virginia Board of Medicine

6. Will the doctors in his plan be
recompensed at a higher rate than
West Virginia physicians?

The list of questions could go
longer, but I think that those will suffice
to point out some inconsistencies in
the medical programs which he backs.

James H. Wiley, M.D.

Morgantown

for Senator Rockefeller

376 THE WEST VIRGINIA MEDICAL JOURNAL

Congress is deciding health system reform

■ ■ ■

Speak up now!

Call (800) 354-9292 now to send
Western Union messages urging
your Senators and Representative
to support the Patient Protection
Act, S 2196 and HR 4527.

Now is the time to urge your Senators and
Representative to support the AMA’s Patient
Protection Act.

Call Western Union at (800) 354-9292 today.
The operator will assure both your Senators
and your Representative receive a Patient
Protection Act message from you.

The charge is $8.25 for three messages and
can be billed to your phone line, MasterCard
or VISA.

The AMA’s Patient Protection Act is a brand
new legislative proposal to help ensure
patients and their physicians — not
insurance companies — will make decisions
about medical care.

The act will give patients everything they
need to know to make fully informed

decisions about their health insurance,
including what restrictions exist on access
to medical specialists.

The Patient Protection Act requires managed
care plans to tell patients what the plan pays
for — and what it does not.

And the act protects the patient-physician
relationship. Health plans will be prohibited
from kicking out doctors for giving patients
appropriate care.

Insurance companies are fighting the Patient
Protection Act tooth and nail. What are they
so afraid of?

Let Congress know you support this
legislation that puts patients first. Take a
stand. Call (800) 354-9292 to send your
message today.

American Medical Association

Physicians dedicated to the health of America

8th FP Weekend/Sports Medicine Conference set

The West Virginia Chapter of the
American Academy of Family Physicians
and the Family Medicine Foundation
of West Virginia will present their 8th
Annual Family Practice Weekend and
Sports Medicine Conference at the
Radisson Hotel in Huntington from
November 11-13-

Sponsors for this year’s event
include the Family Medicine
Foundation of West Virginia, the
Marshall University Department of
Family and Community Health, and
Jose Ricard, M.D., of the Marshall
University Sports Science and
Wellness Institute. The conference has
been reviewed and is acceptable for
18.0 prescribed hours by the AAFP, as
well as AOA credit toward Category
2A for 18.0 hours.

A preconference workshop on
managed care has been scheduled for
Thursday, November 10 from noon to
6:30 p.m., and then the meeting will
officially kickoff on Friday, with
registration at 7 a.m. The first scientific
session will begin at 8:20 a.m. and is
entitled “ The Physical Allergies:
Implications for Exercising Patients ”
by William Briner, M.D., of Parkside
Sports Medicine Center in Park Ridge,
111. The other speakers that morning
will be Earl Foster, M.D., of Scott
Orthopedic Center in Huntington on
“ Common Hand Injuries in Sports; ”
Kenneth Wolfe, M.D., of Tri-State
Otolaryngology in Huntington on "The
Dangers of Smokeless Tobacco Use in
Sports; ” Manuel Molina, M.D., of
CAMC on “ Common Knee Injuries in
Recreational Sports; ” and Ross Patton,
M.D., of Marshall University on
“ Problems in Altitude. ”

Friday afternoon, the sessions will
continue at 1 p.m. with a lecture by
Jim Donnan, head coach of the
Marshall University Thundering Herd,
about “Sports Medicine: Benefits to
Our Athletes. "After Donnan’s
presentation, Joseph Touma, M.D., of
the Huntington Ear Clinic, Inc., and
Phillip Stevens, M.D., of Tri-State
Otolaryngology, will discuss “ Ear
Injuries in Water Sports. ’’Three more
topics will be featured during this
afternoon including “ Managing
Infections in the Outpatient Athlete" by
Richard Quintiliani, M.D., of Hartford

Hospital in Hartford, Conn.;

“ Treatment of Skin and Soft Tissue
Infections" by Ellis Caplan, M.D., of
the University of Maryland; and
"Infectious Complications in Trauma
Patients" by John Kizer, M.D., of WVU.

The CME events will continue on
Saturday morning at 8:15 a.m. with
“ Stalling Complications of Diabetes"
by Julia Breyer, M.D., of Vanderbilt
University. Following Dr. Breyer’s
lecture, Robert M. Guthrie, M.D., will
discuss "Challenge in Clinical Practice:
Changing the Natural History of
Coronary Artery Disease” by Robert
Guthrie, M.D., of Ohio State University.
The next presentation will be
“Cardiologists’ Modem Treatment of
Angina " by Dennis DeSilvey, M.D., of
the University of Virginia. The final
morning lecture is entitled
“ Hypertension and Renal Disease" by
Jay Wish, M.D., of the Cleveland Clinic.

After lunch, the scientific sessions
will reconvene at 1 p.m. with “Irritable
Bowel Syndrome" by Lawrence Schiller,
M.D., of Baylor University Medical
Center. Additional subjects to be
highlighted during the afternoon will
be “Treatment of Obsessive Compulsive
Behavior" by Peter Stokes, M.D., of
New York Hospital; “Choosing the
Appropriate Antibiotic in the 90s: A
Case Study Approach " by Norman
Jacobs Jr., M.D., of Decatur, Ga.;
“Lower Respiratory’ Tract Infections ” by
Richard Brown, M.D., of Baystate
Medical Center in Springfield, Mass.;
and “Sinusitis in the Adult and
Pediatric Population ” by Nelson

Gantz, M.D., of the Polyclinic Medical
Center in Harrisburg, Pa.

Sunday’s programs will also start at
8:15 a.m., and the first talk scheduled
is “ Management of Hypertension in a
Type II Diabetic " by John Levine,

M.D., of Nashville, Tenn. Also on
Sunday morning’s agenda will be
“Treat men t of Commun ity-A cqu i red
Pneumonias" by Gary Stein, Pharm.D.,
of Michigan State University; “Allergic
Rhinitis” by Helen Krause, M.D., of
Pittsburgh; and the concluding lecture
for the conference, “Gastroesophageal
Reflux Disease: Update on Pathogenesis
and Treatment" by Timothy Bulkley,
M.D., also of Pittsburgh.

In addition to the preconference
workshop and the scientific sessions,
this year’s meeting will again feature
exhibits, and a number of business
and social events, including a fund
raising party at Rocco’s Four Seasons
with the Full Tilt Band. For more
information, phone 776-1178.

Mark your calendars
now for Mid-Winter!

This year’s WVSMA’s Mid-Winter
Clinical Conference is scheduled for
January 19-22 at the Radisson Hotel
in Huntington.

Please turn to page 380 for more
details about the conference, or you
may phone Nancie Diwens at
(304) 925-0342 for additional
information.

378 THE WEST VIRGINIA MEDICAL JOURNAL

Dr. Esposito honored
by Cabell County
Medical Society

The Cabell County Medical Society
dedicated its June meeting to honor
one of its members, Dr. Albert C.
Esposito, in recognition of the 20th
anniversary of his success in bringing
the medical school to Marshall
University.

It was on June 5, 1974, that Dr.
Esposito was notified by Senator
Robert Byrd and Richard Roudebush,
secretary of the Veterans
Administration, that one of the new
V.A. assisted medical schools was being
awarded to Marshall University.
According to Roudebush, the new
medical school was awarded to
Marshall University because of Dr.
Esposito’s origination of the concept
of a law to create V.A. assisted medical
schools and his tremendous efforts to
enact this federal legislation. This lawr
was signed by former President Nixon,
whom Dr. Esposito had met with
personally back in 1971 to discuss his
concept of a Veterans Administration
Medical School Assistance Program.

The Cabell County Medical Society
also honored Dr. Esposito in 1978
when they created the Dr. Albert C.
Esposito Lectureship. This lectureship
was turned over to the Marshall
Foundation and included funds for
the portrait of Dr. Esposito and
bronze plaque which are now
displayed at the Marshall University
School of Medicine.

Tulane University,
ACPE create new
master’s degree

Tulane University has announced
the development of a new master of
medical management degree designed
to train physicians for administrative
leadership roles.

This new degree evolved from a
partnership established with the
American College of Physician
Executives. It offers physicians the
opportunity to develop medical
management skills without a significant
career interruption.

The degree will build on the
certificate in medical management
currently offered by ACPE. Physicians
who hold a certificate in medical
management may earn a master’s
degree by completing three one-week
sessions on the Tulane campus in New
Orleans with intervening at-home study.

For more information on the master’s
degree in medical management at
Tulane or the certificate in medical
management, call ACPE at
800-562-8088.

Rush-Presbyterian
schedules liver
disease symposium

" Approaching Liver Disease
Management with Evolving
Therapeutic Techniques" will be the
topic of the Fifth Annual Rush
Symposium on Hepatic and Biliary
Disease and Liver Transplantation at
Rush-Presbyterian-St. Luke’s Medical
Center in Chicago on November 11.

This conference is designed to give
attention to evolving techniques for
successfully treating cholestatic liver
disease, hemochromatosis, and
autoimmune liver disease. A special
registration rate is available for fellows
and postdoctoral students.

To register, call the Transplant
Program Physician Relations
Coordinator at (312) 942-6242.

Reno site of NAHQ
annual conference

The National Association for
Healthcare Quality’s (NAHQ) 19th
Annual Educational Conference will
take place October 2-5 in Reno, Nev.

This meeting is designed to help
prepare health care leaders for the
future by providing them with the
essential tools and techniques of
quality improvement to use in any
health care setting. It will feature five
concurrent tracks, four general
sessions, paper and poster presentations,
special interest networking sessions,
and over 65 exhibitors. Preconference
workshops will also be offered prior to
the conference on Sunday, October 2.

For details, contact the NAHQ at
(708) 966-9392, or fax (708) 966-9418.

ACC, National Health
Council to sponsor
Washington meetings

The American College of Cardiology
is sponsoring a conference entitled
"New Techniques and Concepts in
Cardiology, ” which will be presented
October 20-22 in Washington, D.C.

This meeting is approved for 16
CME credits in the AMA’s Category 1 .
For more information, contact the ACC
at (800) 257-4739 or (301) 897-2695
for outside the U.S. and Canada.

Another conference which will be
taking place this fall in Washington,
D.C., is the National Health Council’s
41st Annual National Health Forum on
“The Three Rs of Environmental Health:
Risk, Reality and Responsibility. ” This
forum is scheduled for September 29
and will feature experts from a
cross-section of the health care and
environmental fields.

For more details, phone Bob
Goldberg at (202) 785-3910.

University of Maryland
to present

endocrinology update

The Division of Endocrinology and
Metabolism and the University of
Maryland School of Medicine are
sponsoring “ Endocrinology Update for
the Practicing Physician 1994 ” on
October 7 and 8 in Baltimore.

This CME event is designated for 10
credit hours in Category 1 for the
Physician’s Recognition Award of the
AMA.

Contact Dorothy Taylor at
(410) 328-2515 for more details.

Annual Clinical update
in pulmonary
medicine announced

The Eleventh Annual Clinical Update
in Pulmonary Medicine has been
announced by Course Director Mervyn
Feierstein, M.D., of the Deborah Heart
and Lung Center in Browns Mills, NJ.
This one-day course will take place at
Bally’s Park Place Casino Hotel and
Tower in Atlantic City, N.J. on
Saturday, December 10.

Sponsored by the Department of
Pulmonary Medicine at the Deborah
Heart and Lung Center, this CME
program is designed to provide
physicians with a balance of
established standards of care and new
methods and therapies in pulmonary
diseases, as well as a state-of-the-art
review of pulmonary disorders
commonly seen in a clinical setting.
Important topics to be addressed
include: asthma management, COPD,
diffuse lung disease, lung cancer,
tuberculosis and non-tuberculous,
mycobacterial infections, pulmonary
fungal infections, pulmonary
complications of HIV infection, and
ethical dilemmas in the ICU.

For further information, contact the
Center for Bio-Medical Communication,
Inc., 80 West Madison Avenue,
Dumont, NJ 07628, (201) 385-8080.

SEPTEMBER 1994, VOL. 90 379

(r ~ \

Don’t be caught in the CME Cold

Join us for the

1995 Mid- Winter Seminars and
Scientific Conferences

January 19-22, 1995
Radisson Hotel - Huntington

The WVSMA's Mid-Winter Sessions will be held in conjunction with the Fourth Annual Scientific
Meeting of the West Virginia Chapter of the American College of Physicians. Call the WVSMA at
(304) 925-0342 for more information.

Special topics to be featured include:

Joint Sessions

"Use of Growth Hormone in the Adult and Aging Population"

"New Concepts in Gastro-esophageal Reflux Disease and Ulcer Disease"

"Lessons Learned from Vaccine Use During the Past 40 Years"

"Peripatetic Plastic Surgeons: Benefactors of Mankind or Innocents Abroad?"

Physician/Public Session Sexually Transmitted Diseases

"Health System Reform/Managed Care" "Human Papilloma Virus Infections"

"Treatment of Chlamydia, Gonorrhea and Other
Sexually Transmitted Diseases"

Controversies in Medicine Potpourri of Topics

"Screening Mammography" "Pain Control, Assessment and Treatment:

"Coronary Artery Disease: Medical vs. Surgical Post-Operative and Terminal"

Management"

^ — - ■ J)

SUCCESSFUL

MONEY

MANAGEMENT

/|| l

We are pleased to announce the 1994 Successful Money Management Seminar schedule. In three exciting sessions,
the workshop introduces you to key concepts and practices of wise money management. You'll learn how to minimize
your taxes, maximize your investment returns, and provide a secure future for yourself and your family.

Another Member Benefit From Your Association!

Areas of Discussion!

Seminars Consist of Three Sessions
6:00 PM - 9:30 PM

• 1993 Tax Law Overview

- Summary of the new Tax Law

- New Opportunities in tax planning

• Estate Planning

- The probate process

- Wills, Trusts, Estate Taxes

• Equity/Fixed Income Investments

- Stocks, Bonds, Ltd Partnerships

- Purchasing strategies. Asset allocation

• Retirement Planning

- Qualified Pensions (SEP’s, 401 K. 403B)

- Select Benefit Plans

Lite Meal Served

Clarksburg Area

Wednesdays

September 14th, 21st & 28th

Beckley Area

Wednesdays

October 12th, 19th & 26th

Charleston Area

Wednesdays

November 2nd, 9th & 16th

Registration Fee $250.00
Spouse Fee $125.00

Spouse’s fee waived if registered 10 days before start of seminar.

If you would like to have a special seminar done in your area, notify
the Medical Association. We will be happy to accommodate you.

Fayette County

Thursdays

December 1st, 8th & 15th

□ Clarksburg Area

September 1994

-J Beckley Area

October 1994

□ Charleston Area

November 1994

□ Fayette County

December 1994

Reserve Your Place!

Don’t Wait!!!

Remember, spousal fee is waived if reservations are confirmed 10 days prior to the seminar date
Return this self-addressed card, or call the WVSMA at (304) 925-0342.

Please Call Today!!!

Name

Spouse’s Name If Attending

Address

City State Zip

Phone Office

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Marshall University - Huntington
September 30

“4th Annual Cancer Conference,” St.
Mary’s Hospital

October 1

“8th Annual MU School of Medicine
Alumni Weekend,” Radisson Hotel

October 8

“Behavioral Management of the
Demented Nursing Home Patient,”
Glade Springs

Robert C Byrd Health Sciences
Center of WVU - Charleston

October 6

(Teleconference) “Gestational
Diabetes in Pregnancy,” David G.
Chaffin, M.D.

October 20

(Teleconference) “Emergency
Department Approach to the Febrile
Pediatric Patient,” Dept, of Emergency
Medicine, CAMC and Women and
Children’s Hospital

Robert C Byrd Health Sciences
Center of WVU - Morgantown

September 23-24

“The 15th Annual Clinical
Ophthalmology Conference”
(sponsored by WVU Dept, of
Ophthalmology and the WV
Academy of Ophthalmology),
Lakeview Resort and Conference
Center, Morgantown

October 7-8

“Pediatric Oktoberfest ‘94’”
(sponsored by the WVU Dept, of
Pediatrics), Robert C. Byrd HSC of
WVU, Morgantown

October 21-22

“Surgery Update” (sponsored by the
WVU Dept, of Surgery and WV
Chapter of the American College of
Surgeons), Robert C. Byrd HSC of
WVU, Morgantown

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Fairmont ★ Fairmont General Hospital,
Oct. 4, 7:30 p.m. “Pediatric Cardiology
Update,” Stanley Einzig, M.D

Gassaway □ Braxton County Memorial
Hospital, Sept. 28, 6:30 p.m., “Trauma
Resuscitation: Optimizing in the
Golden Hour,” Trauma Services

Lewisburg □ WV School of Osteopathic
Medicine, Sept. 27, “Diabetic Eye
Disease,” Michael P. Varley, M.D.

Logan □ Logan General Hospital, Sept.
16, 11:45 a.m., “Trauma Resuscitation:
Optimizing in the Golden Hour,”
Trauma Services

Man □ Man Appalachian Regional
Hospital, Sept. 21, 6:30 p.m., “Disease
of the Larynx,” James T. Spencer, M.D.

Martinsburg ★ VA Medical Center,

Oct. 6, 3 p.m., “Acute Respiratory
Failure,” Harakh Dedhia, M.D.

New Martinsville ★ Wetzel County
Hospital, Oct. 13, noon, “Exercise
Testing for the Primary Care
Physician,” Anthony Morise, M.D.

Oak Hill □ Plateau Medical Center,

Sept. 27, 6:30 p.m., “The Pitfalls in the
Initial Evaluation of the Trauma
Patient,” James W. Kessel, M.D.

Parkersburg □ Camden Clark Hospital,
Sept. 29, noon, “Diabetic Eye
Disease,” R. Mark Hatfield, M.D.

Point Pleasant □ Pleasant Valley
Hospital, Sept. 22, noon, “Medical
Oncology Emergencies,” Steven
Jubelirer, M.D.

Richwood □ Richwood Area Medical
Center, Sept. 20, 5:15 p.m.,
“Management of Low Back Pain,”
Kenneth Wright, M.D.

Spencer □ Roane General Hospital,
Sept. 20, 12:15 p.m., “Trauma
Resuscitation: Optimizing in the
Golden Hour,” Trauma Services

White Sulphur Springs ★ The

Greenbrier Clinic, Sept. 26,

4 p.m., “Breast Cancer,” Edward
Crowell, M.D.

★ The Greenbrier Clinic, Oct. 24,

4 p.m., “Office Practice of Sports
Medicine,” William Post, M.D.

*To be announced

Searching for
the Cure.

Cancer sounds like such a
grown-up disease, but each year,
more than 6,000 American
children will be stricken. The
doctors and scientists at St. Jude
Children’s Research Hospital are
working to wipe childhood cancer
from the face of the earth. To
learn more about this life-saving
work, please call 1-800-877-5833.

ST. JUDE CHILDREN'S
RESEARCH HOSPITAL

Danny Thomas. Founder

^ ■

382 THE WEST VIRGINIA MEDICAL JOURNAL

Poetry Corner y

September

26-27— The Transition from Clinician to
Manager: Administration in Human Service
Organizations (sponsored by The Menninger
Clinic), Topeka, Kan.

26- 28-The 18th National Conference on
Correctional Health Care (sponsored by the
National Commission on Correctional Health
Care), San Diego

28- Oct. 1— American Association for the
Surgery of Trauma, San Diego

29- The Three Rs of Environmental Health:
Risk, Reality and Responsibility, the National
Health Council’s 41st Annual National
Health Forum, Washington, D.C.
29-30-Healthcare Quality Management:
Review and Study Session (sponsored by
the National Association for Healthcare
Quality), Reno, Nev.

29-Oct. 1-Second Annual Conference of
Rural Health Clinics (sponsored by The
National Rural Health Association),

Arlington, Va.

October

1— Dementia Update (sponsored by Ohio
State University), Columbus

6- 9-38th Annual Meeting of the American
Society of Internal Medicine, Dallas

7- 8-Endocrinology Update for the Practicing
Physician 1994 (sponsored by the University
of Maryland School of Medicine), Baltimore
7-8-Cardiology Update 1994 (sponsored by
Ohio State University), Columbus
l6-19-l6th Annual Meeting of the Society
for Medical Decision Making, Cleveland
21-22-Communication Approaches for
Tracheostomized and Ventilator Dependent
Patients (sponsored by Voicing!, Inc.) New
York City

24-28-Prevention in Practice: Workplace
Health in the 21st Century (sponsored by
the American College of Occupational and
Environmental Health), Denver

27- 30-The First International Conference on
Prevention (sponsored by the World Health
Organization, The Council of Geriatric
Cardiology, The Center for the Study of
Aging, The Lawrence Frankel Foundation,
the Robert C. Byrd Health Sciences Center
of WVU, the three medical colleges of West
Virginia, and Senator Jay Rockefeller),
Charleston, W.Va.

28- 29-Clinical Innovations in Ob/Gyn
Ultrasound (sponsored by the American
Institute of Ultrasound in Medicine), New
York City

Caring For Generations

Then

I was an aide in sixty-three,

In a long-term care facility.

Patients ' needs were cared for on the spot,

Whether they wanted it done or not!

The patient's rights was a term yet unheard,

The doctor's wishes were our final word.

I didn 't question, did what I was told.

We nagged, we bossed, we even used to scold!

They took their pills, with or without a fuss,

Then all were told , we know best, trust us.

The patients all did just as they were told.

But this was in “Nursing Home days of old. ”

Now

Now I'm a nurse and again you see,

I work in a long-term care facility.

But everythings is oh so different now,

The patient has rights and they're stressed, and how.

We don ’t do a treatment or dare give them pills,

Until we take time to explain all their ills.

Our residents live here, and this is their place,

The staff watches over them, but gives them space.

Residents can have company any old time,

Hours aren’t restricted, no “Keep Out” sign.

With their consent, we care for them, body and mind,
Caring for them has its own rewards, we find.

Then and now, it’s our main declaration,

We still care, for all our generations.

Twyla E. Vincent, R.N., B.S.N.

Please address your submissions for Poetry’ Comer to Stephen D. Ward, M.D.,
For More Information . . . Editor, West Virginia Medical Journal, P. O. Box 4106, Charleston, WV 25364.

Contact the Journal at (304) 925-034

SEPTEMBER 1994, VOL. 90 383

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health

Bureau examines role of public health in health care reform

The Bureau of Public Health is joining agencies around
the nation in undertaking a number of activities to ensure
that public health is an important component of any state
or federal health care reform package.

The mission of public health is to prevent illness and
injury. In the U.S., more than 500,000 people work at the
federal, state, county and municipal levels to carry out this
mission and the following public health core functions:

* Preventing epidemics

* Protecting the environment, workplaces, housing,
food and water

* Promoting healthy behaviors

* Monitoring the health status of the population

* Mobilizing community action for health

* Responding to disasters

* Assuring the quality, accessibility, and accountability
of medical care

* Reaching out to link high risk, disadvantaged to
needed services

* Providing medical care when needed

* Securing a skilled public health workforce

* Researching for new insights and innovative solutions

* Leading the development of sound health policy and
planning

Currently, less than 1% of the national budget for health
care expenditures is devoted to functions of public health,
while the remainder is targeted for medical treatments. Yet,
nearly 70% of early deaths in the U.S. could be prevented
by population-wide public health approaches, compared to
about 10% that could be prevented by medical treatment,
and 20% that are genetic and could not prevented.

To fund fully effective public health services, only $100
per person per year would be needed, compared to nearly
$4,000 per person per year that is currently being spent in
sick care. Investing in public health can keep the nation's
citizens well and safe, and can save billions of dollars in
sick care costs. For example, every dollar invested in:

* chicken pox vaccinations saves $5.40 in sick care and
hours of lost work.

* stop smoking programs for pregnant women saves
$4.40 in sick baby care.

* AIDS prevention saves upward of $15 in sick care.

In addition, a 3% reduction in:

* the 265,000 coronary bypass operations performed each
year would save $240 million a year in sick care if there
were more public programs on exercise and nutrition

* the 1 . 1 million new cases of lung cancer diagnosed each
year would save $780 million in sick care - - realized
with the aid of public health smoking prevention and
cessation campaigns

* the 600,000 strokes suffered each year would save $396
million a year - - realized with the aid of public health
high blood pressure control programs

* the 140,000 disabilities caused each year by farm accidents
would save $108 million a year - - realized with the aid of
public health safety programs

These measures alone could save as much as one and
one half billion dollars every year. Annual sick care costs
from preventable illnesses include:

* $100 billion - injuries

* $70 billion - cancer

* $135 billion - cardiovascular diseases

* $1.6 billion - fetal alcohol syndrome birth defects

* $4.3 billion - lead toxicity in children under sLx

Heart disease remains the number one cause of death in
West Virginia, taking the lives of nearly 7,000 state resi-
dents last year. That accounted for approximately 35% of
all state deaths in 1993, with cancer accounting for another
23%, and cerebrovascular diseases accounting for 6%.
Throughout the 20th Century, the leading causes of death
in the state and the nation have shifted dramatically from
infectious diseases to chronic conditions. More sanitary
living conditions, the discovery and administration of
immunizations and other numerous public health activities
have helped to reduce and even eliminate many of those
infectious diseases that threatened the population in years
past. Yet, when federal funding for tuberculosis control
was cut in the 1980s, it took only a few years for TB case
rates to begin climbing again.

Whether or not health care reform policies are passed this
year in the Legislature or in Congress, several organizations
are moving ahead to confront public health concerns in
West Virginia. Earlier this year, the Bureau of Public Health
joined the West Virginia Public Health Association and the
Association of Local Health Departments in publishing a
white paper entitled, “ Public Health in a Reformed Health
Care System.” In addition, Bureau Commissioner William T.
Wallace Jr., M.D., M.P.H., has appointed a 20-member panel
to address public health concerns and to offer progressive
solutions to them.

For more information, contact the Bureau of Public Health
at (304) 558-2971.

384 THE WEST VIRGINIA MEDICAL JOURNAL

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Robert E. Pollard, MD

Specializing in
Head and Neck Cancer
Surgery
Ear Surgery
Microsurgery
Endoscopy
Laser Surgery

THE EYE AND EAR CLINIC OF CHARLESTON, INC.

1306 KANAWHA BOULEVARD, EAST
CHARLESTON, WEST VIRGINIA 25328
(304) 343-4371 OR 1-800-642-3049 (WV)

FAX (304) 353-0215

Robert C. Byrd
Health Sciences Center

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Former University
Hospital is renamed

The former University Hospital has
been renamed the Hazel Ruby
McQuain Pavilion in honor of her
support of WVU.

“The support Hazel Ruby McQuain
has given this institution has helped
establish a comprehensive, modern
facility for medical care and training,”
said University President Neil Bucklew.
“The naming of this pavilion in her
honor is an expression of the gratitude
we share for Mrs. McQuain, who has
done so much to advance health care
for residents of West Virginia and the
surrounding region.”

McQuain’s contributions to WVU
exceed $13 million. The centerpiece of
the WVU's medical care is Ruby
Memorial Hospital, which is named for
McQuain’s late husband, John Wesley
Ruby. A gift of $8 million from
McQuain in 1984 helped make the new
hospital possible. It was the largest
single donation in WVU history, and it
ranks among the most significant acts
of individual philanthropy in support
of higher education and health care in
the region.

The Hazel Ruby McQuain Pavilion,
referred to as Health Sciences South
since the opening of Ruby Memorial
Hospital, houses clinics for family
medicine and dentistiy, the Center for
Rural Emergency Medicine and the
School of Nursing, and other facilities.

WVU to affiliate with
The Health Plan

Residents of north central West
Virginia will soon have the option of
joining the state’s largest and oldest
health maintenance organization.

The affiliation of the Robert C. Byrd
Health Sciences Center of WVU with
The Health Plan of the Upper Ohio
Valley will bring together two large
non-profit health care organizations.

“We are certain the alliance of
WVU and The Health Plan will
represent a very strong, attractive
choice for people who are ready to
opt for an HMO,” said Philip D.
Wright, president of The Health Plan.

According to Dr. Robert D’Alessandri,
vice president for health sciences and
dean of medicine at WVU, HMOs are
very effective at containing costs.

“We’ll put emphasis on prevention
and wellness, as well as education of
members,” Dr. D’Alessandri said. “We
intend to keep as much health care as
possible in the local communities of
The Health Plan members. Our main
goal is to continue to provide quality
services while containing costs.”

Vale cited in New
York Times article

Dr. Janie Vale,
assistant professor
of occupational
medicine and
orthopedics, has
been cited in the
New York. Times for
pioneering an
upper extremities
cumulative trauma
disorder screening
and intervention
protocol.

At a Tyson Foods poultry processing
plant, worker’s compensation fees
were reduced to $1,000 from $106,000
in two years through a comprehensive
ergonomics and medical management
program designed by Dr. Vale.

Granke becomes
registered cardio tech

Dr. Kenneth Granke, assistant
professor of surgery, recently became a
registered cardiovascular technologist
and was asked to sit on the Board of
Exam Writers of Cardiovascular
Credentialing International.

Dr. Granke also recently attended
the joint meeting of the Northeastern
Chapter of the International Society of
Cardiovascular Surgery and Vascular
Surgery in Seattle.

Vale

Chisholm co-chairs
surgery symposium

Chisholm

years of progress f

Dr. Lionel

Chisholm, professor
of ophthalmology,
recently co-chaired
the Vitrectomy
Surgery Symposium
at the International
Congress of
Ophthalmology
in Toronto.

This symposium
addressed the 25
this surgical field.

Saw participates in
physicists’ meeting

Cheng B. Saw, Ph.D., associate
professor of radiation oncology,
recently attended the American
Association of Physicists in Medicine
annual meeting in Anaheim, Calif.

Dr. Saw chaired a session on
brachytherapy at the meeting and also
presented three papers co-authored
by Dr. Leroy Korb, associate professor
and section chief, and Todd Pawlicki,
MS, radiation oncology.

Orthopedic faculty
present research

Several research projects of faculty
in the Department of Orthopedics
were presented at the World Congress
of Biomechanics in Amsterdam in July.

Associate professor Dr. Jaiyoung Ryu,
and Assistant Professor Jungsoo Han,
Ph.D., had 7 projects accepted. In
addition, Assistant Professor Corrie
Mancinelli, P.T., Ph.D., and Dr. J. David
Blaha, professor and chair, also had a
project accepted as an oral presentation.

Macsai elected to EABB
executive committee

Dr. Marian Macsai, associate professor
of ophthalmology, has been recently
elected to the Executive Committee of
the Eye Bank Association of America.

386 THE WEST VIRGINIA MEDICAL JOURNAL

Just

WESPAC

Dolt!

WESPAC has a new club - the $365 Club, "A Dollar
A Day". Just think about it, a dollar a day can help
reform the health care system and protect your
rights as physicians as well as the rights of your
patients.

Don't wait, the time to act is now!

Send your personal check to WESPAC and become
involved!

WESPAC
P.O. Box 4106
Charleston, WV 25364
304/925-0342

Contributions for WESPAC/ AMPAC are not deductible as charitable
contributions for federal income tax purposes. A portion, of your
WESPAC contribution is sent to AMPAC thus enrolling you as an
AMPAC member as well.

YOCON*

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine's peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug. Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone

Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocon ! is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.

Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history. Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.12 Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 ■3 4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to 'h tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon* 1/12 gr. 5.4 mg in
bottles of 100’s NDC 53159-001-01 and 1000’s NDC

53159-001-10. jpspigj

References:

1. A. Morales et al. . New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed , p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,

1983.

4. A. Morales etal ., The Journal of Urology 128:

45-47, 1982.

Rev. 1/85

AVAILABLE AT PHARMACIES NATIONWIDE

PALISADES

PHARMACEUTICALS, INC.

64 North Summit Street
Tenafly, New Jersey 07670

(201) 569-8502
1-800-237-9083

Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

PBS special to
highlight Internet,
RuralNet

Computer outreach activities of the
School of Medicine will be featured in
an upcoming Public Broadcasting
System documentary about the
Internet.

Scheduled to air in December, the
program will show viewers how to
access the Internet and highlight
several innovative ways it is being
used, according to Brandenburg
Productions producer Phillip Byrd.

“We want to show how the Internet
really affects people’s lives, that it’s
not just CB radio via e-mail,” he said.

After reading about Marshall’s
Science by E-mail program in a
compilation of “500 Neat Things on
the Internet,” Byrd and his colleagues
came to Marshall in July to film a
segment about that program. Once
here, they became so intrigued by
Marshall’s computer network linking
rural medical centers that they quickly
revised their plans so they could
include RuralNet as well.

“We found people at clinics in rural
West Virginia — not what one would
think of as a major medical center —
working with the most current, up-to-
date medical information,” Byrd said.

Created to support Marshall
students who were spending nine
months at rural sites through the Rural
Physician Associate Program, RuralNet
soon expanded to serve the hundreds
of health professions students
working at rural sites throughout West
Virginia through the Kellogg
Community Partnership Program and
the Rural Health Initiative. RuralNet
allows students to communicate with
one another and their professors as

well as to access educational and
worldwide clinical resources.

In addition to helping students and
providers gather information from
anywhere in the world, RuralNet in
turn offers Internet users worldwide to
tap into the school’s collection of rural
health resources.

Harts High School officials opened
the school in late July so that Carol
O’Connell and her students could re-
enact their Science by E-mail
activities. With the cameras rolling,
students used electronic mail to talk
with a mentor and used a popular
Internet tool called a gopher to
connect to the National Aeronautics
and Space Administration.

Dr. Susan DeMesquita of Marshall,
who with Professor Jan Fox
developed the Science by E-mail
project, said the public school
students became quite adept at
traveling the information
superhighway.

“Some of the students contacted
Tasmania and began conversing
electronically with pen pals there,”
she said. “They certainly proved that
although our geography is isolated,
our students don't have to be. They
just needed more opportunity. They
had 30 students using one computer
for one 45-minute period a day; they
actually came to physical blows on
the playground over who got to use it
first. If they had had 10 or 15
computers, they would have had pen
pals all over the world."

Competition may not be so fierce in
the future, thanks to the public
television visit.

“We were afraid that the computer
at Harts would not be one we could
shoot for technical reasons, so we
asked Compaq, which was
underwriting the program, to provide
a computer we could take with us,”
recalled producer Byrd. "The person
we were working with agreed, but
then someone at Compaq said ‘No . . .
one isn’t enough,’ and so the
company sent the school three new
computers.”

MARSHALIMJNIVERSITY

First Project SEED
students complete

Two Tri-State high school students
recently completed their participation
in the first Project SEED Program at
the School of Medicine. Project SEED
is the American Chemical Society’s
social action program providing high
school students with an opportunity
to work as part of a team doing
hands-on research. The research
apprenticeship experience provided
by Project SEED contributes to career
development and educational growth
of the students.

Dr. William B. Rhoten, chair of the
Department of Anatomy Cell and
Neurobiology, received national
competitive funding from the
American Chemical Society for the
program. Aleisha Blake of Huntington
East High School worked with M.
Aslam Chaudhry and Dr. Rhoten on
the research topic “Chemistry at the
Cellular Level.” Nadine Bridges of
Huntington High School worked with
Dr. Igor N. Sergeev, Michelle Carney
and Dr. Rhoten on “Calcium and the
Living Cell.”

Mufson, colleagues
awarded Louis
Weinstein Award

Dr. Maurice A. Mufson of Marshall
and research colleagues in Houston
have received the Louis Weinstein
Award of the journal Clinical
Infectious Diseases. The award honors
the best clinical article published in
the journal between July 1993 and
July 1994.

The article for which they were
honored is entitled "Antibody to
capsular polysaccharides of the
Streptococcus pneumoniae:
prevalence, persistence and response
to revaccination.” Published in July
1993, the article describes in part the
findings of Dr. Mufson’s research on
pneumococcal vaccine and antibody
responses of elderly persons.

388 THE WEST VIRGINIA MEDICAL JOURNAL

THE WHEELING CLINIC

WHEELING, WEST VIRGINIA 26003

Wheeling, 234-2000 • St. Clairsville, (614) 695-2511 • New Martinsville area, 455-2222 • Wellsburg-Steubenville area, 737-3700

INTERNAL MEDICINE
General

P. Heyat, M. D. (St. Clairsville)
P. R. Hedges, M. D.

G. Ortiz, M. D. (St. Clairsville)

Peripheral Vascular Disease

J. D. Holloway, M. D.

Cardiovascular

A. M. Valentine, M. D.

W. E. Noble, M. D.

Kris Reddy, M. D.

J. Dalai, M. D.

A. E. Frenn, M. D.

Rheumatology

R. Vawter, M. D.

GENERAL SURGERY

E. C. Voss, M. D.
G. Galvin, M. D.

OPHTHALMOLOGY

R. V. Pangilinan, M. D.

D. Simbra, M. D.

H. F. Leeper, M. D., Ph.D

D. B. Christie, M. D.

Kathryn M. Clark, O. D.

OTOLARYNGOLOGY/

MAXILLO FACIAL SURGERY

W. A. Tiu, M. D.

A. G. Matadar, M. D.

RADIOLOGY

Valley Radiologists, Inc.

FAMILY PRACTICE

E. L. Coffield, M. D. (New Martinsville)
C. P. Entress, M. D.

T. H. Korthals, M. D. (St. Clairsville)

J. H. Mahan, M. D. (St. Clairsville)

PODIATRY

B. Blank, D.P.M. (St. Clairsville)

DERMATOLOGY

G. A. Ganzer, M. D.

NEUROLOGY

H. L. Kettler, M. D.

ANCILLARY SERVICES
Optical

Speech Therapy/Audiology

Dietetic Counseling

Electrology/Cosmetic Therapy

Electrocardiography

Electroencephalography

Neurological Studies (Non-invasive)

Roentgenology

24° A/EEG Scanning Service

Cardiac Ultrasound

Clinical Laboratory

MANAGERS 7
/ ASSOCIATION

Join us for the Eighth Annual Conference

The Business Side of Medicine

November 1042, 1994

Canaan Valley Resort, Inc.

Davis, West Virginia

Topics include: "But That's the Way We've Always Done it"

"Excelling in Economics"

"Are Your Accounts Receivable Healthy ?-If Not, Here's the Cure"
"Professional Presence, Power and Image"

"The Business Side of Medicine"

"Here Comes De' Judge, Here Comes De' Judge"

Grand Prize Drawing for Early Bird Registration by August 3 1
For registration information contact:

Office Managers Association of Health Care Providers, Inc.

P.O. Box 3850, Charleston, WV 25338 (304)348-2545

Med Student
Section

Our future is so bright we’ve got to wear shades

Dear Fellow Medical Students:

Well, I’m not really wearing sunglasses as I write this, but I couldn’t be more pleased and excited about
three recent events which took place during the WVSMA's Annual Meeting at The Greenbrier that will have a
very positive effect on the future of the WVSMA-MSS.

The first significant act was the passing of our resolution to create a Commitee on Graduate Medical
Education by the members of the WVSMA’s House of Delegates. I was able to attend this year’s WVSMA Annual
Meeting with four other students and we were welcomed with much encouragement and praise.

During the meeting, I was also extremely pleased to be able to visit the West Virginia School of
Osteopathic Medicine with AMA Account Representative Don Foy; WVSMA’s Membership Coordinator Donna
Webb; and WVSMA-MSS Vice President Nick Cottrell. Our purpose was to recruit students into the WVSMA-MSS
and encourage them to establish a component society. Most of the students were very enthusiastic, and as a
result of our visit, 28 osteopathic students have joined the WVSMA-MSS as of September 1.

The third important event that took place at the WVSMA’s Annual Meeting was that the board for
WESPAC, the WVSMA's political action committee, voted to include medical students and residents as
contributors to WESPAC. The board set the contribution levels at $10 for students and $25 for residents. These
are the minimum levels, but students and residents are welcome to contribute more if they wish. This new role
provides us with the chance to become more politically active, and I hope if you have not yet registered to vote
you will do so as soon as possible. REMEMBER - - THE GENERAL ELECTION IS NOVEMBER 8. Please take
the initiative and help make positive changes in the practice of medicine through the leaders we elect.

In other news, the Huntington and Morgantown component societies recently participated in their
respective schools’ orientations. The incoming medical students were provided lunch by the WVSMA-MSS and
introduced to the WVSMA and AMA. We have been utilizing the Outreach Program sponsored by the AMA to
gain new members and increase the strength and voice of the Medical Student Section. Both campuses were
very successful with this year’s orientations, and we look forward to the input from our new members.

The Medical Student Survey results are still being analyzed. As I stated in the July issue of the Journal,
our objective is to demonstrate the most important factors and concerns that medical students in West Virginia
have about health care reform and rural medicine. We have received approximately 40% of the more than 800
surveys mailed, and the results will also be including the classes of 1998, who received the survey during their
orientations. We hope to publish an article in the Journal later this year, since many legislators and other state
leaders are interested in our results and conclusions.

The WVSMA-MSS is continuing to be recognized more and more as an active and beneficial part of the
WVSMA. I attribute much of our success during this past year to Dr. Comerci, who has given us endless
encouragement and support. I want to extend my sincerest thanks to Dr. Comerci for always taking the time to
speak with us and include us in WVMA functions.

In closing, I would like to welcome all the new WVSMA-MSS members, and say how much we are
looking forward to working with Dr. Denny Burton, the new president of the WVSMA.

David C. Faber, MS III
WVSMA-MSS President

390 THE WEST VIRGINIA MEDICAL JOURNAL

4th Annual Vascular Surgery Seminar:

Symposium on Aneurysms

Saturday, October 15, 1994

Featured

John J. Bergan, MD

Past President, The Society for

Vascular Surgery

Clinical Professor of Surgery,

University of California, San Diego

Uniformed Services

University of the Health Sciences,

Bethesda

Jerry Goldstone, MD

President-Elect of the North
American Chapter of the Int'l
Society of Cardiovascular Surgery
Professor and Vice-Chairman,
Department of Surgery,
University of California,

San Francisco

Speakers:

Thomas Riles, MD

Professor of Surgery
Director, Division of Vascular
Surgery,

New York University
Medical Center

Frank J. Veith, MD

President-Elect of the Society for
Vascular Surgery
Prof., Combined Dept, of Surgery
Chief, Vascular Surgical Services
Montefiore Medical Center,
Albert Einstein College of
Medicine, Bronx, New York

Program Director:

Ali F. AbuRahma, MD

Professor of Surgery, Robert C. Byrd Health Sciences Center of West Virginia University, Charleston Division
Chief, Vascular Section, Medical Director, Vascular Laboratory
Charleston Area Medical Center

Location:

Robert C. Byrd Health Sciences Center of West Virginia University, Charleston Division

Charleston Area
Medical Center

For more information, please contact
CAMC Continuing Education and Conference Services, (304) 348-9581 .

RobertC.Byrd
Health Sciences Center

OF WEST VIRGINIA UNIVERSITY

/ N The long, trembling call sends a shiver down your spine, and

then you smile. You've reacted once again to the chilling cry of the
tiny screech owl, West Virginia's most common-and smallest-owl.

Screech owls are found throughout West Virginia from
woodlots to your own backyard. They nest in hollow cavities
and hatch up to five young in late spring. Like all raptors, the
screech owl is federally protected.

Dave Jones, master wildlife sculptor and owner of
Wildthings Sculpture Studios in Lewisburg, has captured the
charm of this diminutive raptor in bronze, the first of an
annual series designed to raise funds for West Virginia's
Nongame Wildlife and Natural Heritage Program. A limited
edition of 200 screech owls will be cast and sold solely to
benefit the Program, which has the responsibility of the con-
servation and monitoring of more than 90% of West
Virginia's wildlife. The money raised from the sale will be
placed into the West Virginia Wildlife Endowment Fund to
work in perpetuity for nongame and endangered species.

Each 10-inch bronze sculpture has a purchase price of $335
(including shipping), of which the West Virginia Wildlife
Endowment Fund will receive $130 for the Nongame
Wildlife and Natural Heritage account. A tax advisor should
be consulted regarding the personal deductibility of this con-
tribution. Each signed and numbered piece will be sold with
a certificate of authenticity and a letter confirming your contribution to the future of West Virginia's
wildlife.

You may order your screech owl by sending a $335 check for each sculpture to: Wildthings Sculpture
Studios, P.O. Box 641, Lewisburg, West Virginia 24901. Telephone: (304) 647-5418.

WESPAC News

We would like to thank the
following physicians and alliance
members for their contributions to
WESPAC:

Physicians

A Dollar A Day Club

*Designates more than $365 in
contributions

Cabell

*Denny Burton
*Phillip R. Stevens
Panayotis Ignatiadis

Kanawha

Ronald Cordell
Sherman Hatfield

Mercer

Charles D. Pruett

Monongalia

Herbert Warden
Vadrevu K. Raju

Raleigh

Ahmed D. Faheem

Regular Members

Greenbrier

Douglas Jones

Sustainer Members

Cabell

Philip B. Lepanto

Kanawha

Horatio Spector
Thomas Douglass

Ohio

John Holloway

Parkersburg Academy

David Avery

Raleigh

Wallace Johnson

Tug Valley

Rano S. Bofill

Tygarts Valley

Joseph A. Noronha

Western

Pedro N. Ambrosio
Erlinda B. Ambrosio

Extra Miler Members

Cabell

James Cochrane

Residents

Regular Members - $25
Gold Members - $26 to $150

Gold Members

Kurt Palazzo
David Hess

Alliance Members

Regular Members

Greenbrier

Ramah Jones

Sustainer Members

Central

Anne Ramirez

Harrison

Sue Bryant

New Members

We would like to welcome the
following new members to the
WVSMA:

Nancy J. Gerber, MD
1502 Harrison Avenue
Elkins, WV 26241

Kourosh Ghalili, MD
3100 MacCorkle Avenue
Suite 411

Charleston, WV 25301

Timothy J. Gore, MD
130 Goff Mountain Road
Cross Lanes, WV 25313

E. Reed Heywood, MD
830 Pennsylvania Avenue
Suite 304

Charleston, WV 25302

Richard W. King, MD
300 Davisson Run Road
Suite 203

Clarksburg, WV 26301

Rosario L. Nadorra, MD
P.O. Box 1998
Williamson, WV 25661

Roger K. Pons, MD
206 Cottage Avenue
Weston, WV 26452

Paramjit Shergill, MD
Oceana Medical Center
P.O. Box 400
Oceana, WV 24870

392 THE WEST VIRGINIA MEDICAL JOURNAL

health sciences library

UNIVERSITY OF MARYLAND
BALTIMORE

OCT 26 1994

NOT IN CIRC.

West Virginia State Medical Association

October 1994

1 •* *

Wk'-'Q

"^1 ■

1. » AH? A' < P®

•, A. ** , yh
tyl

w^w- / y i

i’t.

Step UP to a more secure financial future

| Sr

You can't always predict when difficulties
may arise. Protect your financial security.

Each of these insurance plans, made

available to membersof the WV State L

Medical Association, plays an important
role in protecting you and your family.

□ Yes, I want to step up to a more secure financial future. Please send me information on the insurance coverage
checked below.

□

Comprehensive Major Medical

□

Term Life

□

Disability Income

□

Long Term Care

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Address

City

State .

Zip

Daytime Telephone Number

Best Time to Call

Mail to: Acordia of WV, Attn: WV PIT, One Hillcrest Drive, East, P. O. Box 3186, Charleston, WV 25326-3186

EDITOR

Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Postmaster send form 3579 to the West
Virginia Medical Journal. 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL IOURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston.
WV 25304.

Subscription Rates: $36 a year in the U.S.;
$60 in foreign countries; $3 per single copy.
Address communications to the West
Virginia Medical Journal. P O. Box 4106,
Charleston, WV 25364.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Road,
Ann Arbor, MI 48106.

USPS 676 740
ISSN 0043 - 3284

West Virginia Medical

OURNAL

Contents

Special Section • Convention Report

Photo Highlights 403

1994 Resolutions 412

Annual Reports 414

Scientific Newsfront

Alzheimer’s disease: A new hope 418

A post-thyroidectomy convulsion: An unusual presentation
of chronic hypoparathyroidism 420

Manuscript Guidelines 421

Hantavirus Pulmonary Syndrome

Medical Grand Rounds from the Robert C. Byrd

Health Sciences Center of West Virginia University 422

President’s Page

Choose wisely 428

Editorial

Politics and Medicine 429

In My Opinion

Medical care - A tale of four countries 430

Letter to the Editor

Medical Assurance: By and for physicians 431

Special Departments

General News 434

Continuing Medical Education 436

Medical Meetings/Poetry Corner 437

Bureau of Public Health News 438

Robert C. Byrd Health Sciences Center of WVEJ News 440

Marshall University School of Medicine News 442

Alliance News 444

1993 Annual Audit 446

Obituary 448

Classified 449

October Advertisers 450

Front Cover

A beautiful fall scene at Ritter Park in Huntington. Photo
courtesy of Mrs. Linda Turner of Huntington, a past
president of the WVSMA Alliance.

OCTOBER 1994, VOL. 90 401

CONVENTION REPORT ’94

S i

Highlights of the West Virginia State
Medical Association's 127th Annual Meeting

August 17-20, 1994
The Qreenbrier

White Sulphur Springs, West Virginia

We wish to thank the participants of the WVSMA’s 127th Annual Meeting.
Your commitment and support strengthens the Association and is vital to its
continued success.

Among the guests at this year’s Executive Committtee/Council Luncheon were (from left)
Dr. David Avery, Dr. Rutherford Sims, Dr. John Holloway, Executive Committee members
Dr. James Helsley and Dr. Dennis Burton, and Dr. Edward Arnett.

During the Council meeting, Dr. John Markey
gestures as he presents a report on the
companies who made bids to be the WVSMA’s
endorsed professional liability carrier.

At the Presidential Reception, Dr. James Comerci, WVSMA
president for 1993-94, visits with the President of the Indiana State
Medical Association Dr. William VanNess and his wife, and Dr.
James Shield Jr., president of the Medical Society of Virginia.

Dr. Phillip Stevens, chairman of the 1995 Annual Program
Committee, and his wife, Susan, enjoyed spending time at the
Presidential Reception with Mimi Vass, the wife of Rob Vass of
Acordia of West Virginia.

In the midst of the Council Meeting, Dr. John Dr. and Mrs. Henry Hills Jr. of Charleston were happy to be a part of this

Holloway uses a little humor to make a point. year’s meeting.

OCTOBER 1994, VOL. 90 403

Dr. Richard Lang of the Cleveland Clinic delivered
this year’s Edmund B. Flink Address on
“Prevention in the 1990s. ”

“Current Management of Extracranial Cerebral
Vascular Disease" was the topic of the Thomas L.
Harris Address presented by Dr. John Bergan of
the University of California.

WVSMA Executive Director George Rider (right) greets Jim Cates, Steve Brown and
Tom Phelps of Medical Assurance of West Virginia; and Tamara Lively and Heather
Sipes of Acordia of West Virginia at their booth in the Exhibit Hall.

Dr. Ron Stollings of Madison was the recipient of the Rural
Physician of the Year Award, which he dedicated to the memory
of his mother, Alma, for her influence on his career.

Claire Spralding of Medicare
Operations for Nationwide Mutual
Insurance Company was proud to
accept the Presidential Citation for
her colleague, Deanna Myers of
Sissonville, who is critically ill.
Deanna is the district Medicare
manager for Nationwide, and she
was selected for this honor
because of her contributions in
enhancing health care and the
medical profession.

404 THE WEST VIRGINIA MEDICAL JOURNAL

Dr. David Morgan and his wife, Mary Jane, were
delighted and honored with the award Dr. Morgan
received from Wyeth-Ayerst for his outstanding
contributions to community service.

Dr. Peter Kim Nelson of New York University Medical Center answers a participant’s
question about cerebral vascular disease during a panel discussion for the General
Scientific Session with Dr. C. Douglas Phillips of the University of Virginia.

Jan Woerth, Ph.D., president of J.K. Woerth, Inc., directed a Lunch and Learn
program entitled “ Managed Care . . . Minimizing the Risks,” which featured input
from several visiting dignitaries.

Dr. Robert Pulliam comments on a point made by
Dr. Richard Lang following his Edmund B. Flink
Address.

Dr. Russell Biundo of MountainView Rehabilitation
Hospital in Morgantown directs a question to one
of the speakers during the General Scientific
Session on peripheral vascular disease.

OCTOBER 1994, VOL. 90 405

Dr. James Comerci delivered a moving Presidential
Address during the First Session of the House of
Delegates.

Alice Jo Hess of Clarksburg and WVSMA Finance
Manager Sue Shanklin fondly look at the WVSMA’s
historical photos which were on display in the
Exhibit Hall.

AMA President Dr. Robert McAfee enjoyed sharing some political insights with
former AMA Delegate Dr. Stephen Ward, who is editor of the West Virginia

Jrmirtinl

WVSMA Finance Manager Sue Shanklin and her husband, Chester, relax after a walk.

Exhibitor Chris Ferrell poses with the beautiful quilt her mother made and donated
for the raffle which was held for the Family Medicine Foundation of West Virginia.

406 THE WEST VIRGINIA MEDICAL JOURNAL

Dr. Ronald Cordell of Charleston, the WVSMA’s
new vice president, addressed guests at the
luncheon for component and specialty society
presidents, past presidents, visiting state
presidents and 50-year graduates.

The lucky winners of door prizes from the WVU School of Medicine
were Dr. Chinmay Datta and Dr. Darryl Landis.

At the reception hosted by Acordia of West Virginia and Medical
Assurance of West Virginia, Inc., Bob Ludwig of Acordia (second
from left) visited with Gay Jackson and Beth Hunt of the Marshall
University School of Medicine, and Dr. Dennis Burton, the president
of the WVSMA for 1994-95.

After the meeting of the Publication Committee, Dr.
Stephen Ward, editor of the West Virginia Medical
Journal (center), was joined by Associate Editors
Dr. Robert Marshall, Dr. Harvey Reisenweber, Dr. Joe
Jarrett, Dr. David Morgan, Dr. Louis Palmer and Dr.
John Hartman for group picture.

OCTOBER 1994, VOL. 90 407

AM A Field Representative Don Foy shows
great form during the golf tournament.

The beautiful grounds of The Greenbrier
provided some great fishing spots for
meeting participants.

;

Dr. Prospero Gogo, who chaired the
tennis tournament, delivers a powerful
serve during one of the games.

Sporting their new volleyball t-shirts from Sandoz, Dr. James
Comerci, his wife, Lynn, and their daughter, Michele, take time out
for a picture after playing in the tournament.

Proudly holding their trophies are golf tournament winners Dr.
Jeffrey Stead; Don Foy, AMA field representative; Dr. Martin Murcek,
president of the Pennsylvania Medical Society; and Dr. Vincent
Townsend.

The “mighty six” to play in this year’s tennis tournament
were Dr. Constantino Amores, Dr. John Holloway, Dr.
Prospero Gogo, Christopher Amores, Dr. William Scaring and
Dr. David Waxman.

408 THE WEST VIRGINIA MEDICAL JOURNAL

AMA President Dr. Robert McAfee received a standing ovation from
WVSMA leaders after his speech on health care reform during the
Second Session of the WVSMA House of Delegates.

AMA Resident Section Delegate Dr. Kurt Palazzo, WVSMA Medical
Student Section President David Faber, and WVSMA Medical Student
Section Vice President Nick Cottrell were proud to assist with
activities during the Second Session of the WVSMA House of
Delegates.

Dr. John Lavery and his wife, Margaret, were ecstatic about winning
a weekend at The Greenbrier at the reception for the new WVSMA
and WVSMAA leaders.

New WVSMA President Dr. Dennis Burton was pleased to celebrate
his inauguration with his wife, Kathi, his mother. Fawn, and his
close friend, Mark McVey. McVey, who is currendy starring in Les
Miserables on Broadway, presented a special evening of musical
entertainment at the reception honoring Dr. Burton and the other
the newly installed WVSMA and WVSMAA officers.

OCTOBER 1994, VOL. 90 409

Bonnie Fidler, past president of the Kanawha Medical Alliance, accepts the Alliance of
the Year Award on behalf of her county from Alice Edwards, chairman of WVSMAA’s
Awards Committee.

Carole Scaring, WVSMAA president for 1993-94, passes the president’s pin to the new
WVSMAA President Sue Bryant.

Ginny Reisenweber proudly holds the plaque
which the Eastern Panhandle Medical
Auxiliary was awarded for having the greatest
increase in membership this year. Pictured
with Ginny is Sue Bryant, WVSMAA president
for 1994-95, who presented the award.

Carole Scaring conducts the WVSMAA’s House
of Delegates meeting.

* | Mm

s - - M

t BMa

E' N H

( • yk MHHH

AMAA President Barbara Tippens inducts
the new WVSMAA officers for 1994-95.
Pictured from the left are Joann Cordell,
Southwest Regional director; Terry Rojas,
Southeast Regional director; Subhra
Datta, Northeast Regional director; Lil
Gordon, recording secretary; Janet
Sebert, treasurer; Amy Ricard, vice
president; Linda Elliott, president-elect;
and Sue Bryant, president.

410 THE WEST VIRGINIA STATE MEDICAL JOURNAL

(r ^

Don't be caught in the CME Cold

Join us for the

1995 Mid- Winter Seminars and
Scientific Conferences

January 19-22, 1995
Radisson Hotel - Huntington

Special topics to be featured include:

Joint Sessions

"Use of Growth Hormone in the Adult and Aging Population"

"New Concepts in Gastro-esophageal Reflux Disease and Ulcer Disease"

"Lessons Learned from Vaccine Use During the Past 40 Years"

"Peripatetic Plastic Surgeons: Benefactors of Mankind or Innocents Abroad?"

Physician/Public Session Sexually Transmitted Diseases

"Health System Reform/Managed Care" "Human Papilloma Virus Infections"

"Treatment of Chlamydia, Gonorrhea and Other
Sexually Transmitted Diseases"

Controversies in Medicine Potpourri of Topics

"Screening Mammography" "Pain Control, Assessment and Treatment:

"Coronary Artery Disease: Medical vs. Surgical Post-Operative and Terminal"

Management"

^ -- - ■ J

Annual Meeting 1994

1994 Resolutions

Resolution 1: (not adopted)

WHEREAS, the State of West Virginia has finally passed
a seat belt law, and

WHEREAS, the current law needs to be strengthened in
regards to mandatory enforcement and stiffer penalties, and
WHEREAS, a strict reinforced seat belt law has shown to
reduce injuries and save lives; therefore be it

RESOLVED, that the WVSMA support a stricter seat belt
law.

(WVSMA existing policy already supports stricter seat belt
legislation.)

Resolution No 2: (not adopted)

WHEREAS, the State of West Virginia has finally passed
a seat belt law, and

WHEREAS, the current law does not require mandatory
seat belt use on school buses, and

WHEREAS, the children of this State are one of our most
important assets; therefore be it

RESOLVED, that the WVSMA support a stronger seat belt
law that requires mandatory seat belts on school buses.
(The committee was not provided with sufficient information
to determine the safety of seat belts on school buses. )

Resolution No 3: (not adopted)

WHEREAS, the Federal Government has proposed some
type of Tort Reform, and

WHEREAS, the State of West Virginia has not passed any
Tort Reform in recent years, and

WHEREAS, The Health Care Planning Commission has
proposed Tort Reform for West Virginia, and

WHEREAS, citizens of West Virginia need Tort Reform to
reduce the cost of medical care; therefore be it

RESOLVED, that the WVSMA support Tort Reform at the
State and Federal level similar to the five principals of MICRA.
(It is already existing WVSMA policy.)

Resolution No 4: (adopted as amended)

WHEREAS, 20% of the cost of medical care is in
administrative costs, and

WHEREAS, insurance companies and third party payors
have different requirements for Utilization Review, and
WHEREAS, this does not contribute to the quality of
patient care; therefore be it

RESOLVED, that the WVSMA support a unified reporting
system of Utilization Review of all third party payors, and
be it further

RESOLVED, that External Utilization Review Agencies be
licensed in this state and thereby be held accountable for
the negative decisions that adversely affect patient outcome.

Resolution No 5: (substitute resolution adopted
as amended)

WHEREAS, West Virginia has a very high rate of tobacco
use, and

WHEREAS, passive smoke inhalation has been shown to
cause health problems, including smoking in public
places, and

WHEREAS, tobacco use has been shown to be a major
cause of health problems; therefore be it

RESOLVED, that the WVSMA support an AMA policy on
Federal Tobacco taxes and an increase in WV Tobacco
Tax to reduce the overall use of tobacco and its deleterious
health effects.

Resolution No 6: (substitute resolution adopted
as amended)

WHEREAS, the AMA-MSS has made GME reform a
priority in its conversations with Congress; and

WHEREAS, the AMA has developed a Campaign on
Workforce Planning; and

WHEREAS, the AMA has established a Task Force
consisting of the Council on Medical Education and the
Council on Long Range Planning and Development to study,
research, and create policy on Physician Workforce Planning
Strategies; and

WHEREAS, the AMA has involved medical students in
hearings, committee, and council meetings on GME reform
issues; and

WHEREAS, Congress has been receptive to AMA-MSS
input in meetings in May 1994 between the MSS and
Congress; and

WHEREAS, current AMA policy resists the imposition of
physician workforce targets (i.e. arbitrary percentage of
primary care physicians the must be produced); and
WHEREAS, current AMA policy encourages efforts to
increase the proportion of physicians entering and
remaining in primary care; and

WHEREAS, WVSMA and AMA publications, mailed to all
MSS members who are in good standing, serve as
educational tools on GME reform issues; and

WHEREAS, West Virginia medical students from the
Marshall University School of Medicine, the West Virginia
School of Osteopathic Medicine, and the West Virginia
University School of Medicine (Charleston and
Morgantown campuses), have been surveyed on their
opinions on GME reform issues, as well as representation
issues and primary care workforce planning issues;
therefore be it

RESOLVED, that WVSMA establish a committee on
Graduate Medical Education to include faculty
representatives from the Marshall University School of
Medicine, the West Virginia School of Osteopathic
Medicine, and the West Virginia University School of
Medicine, four medical student representatives to be
appointed by the WVSMA-MSS Executive Council five
resident physician representatives and other representative
appointed at the discretion of the WVSMA President to
research, study, and review graduate medical education
policies in the state of West Virginia. Be it further
RESOLVED, that the Chair of said committee shall be
appointed by the WVSMA President. Be it further

RESOLVED, that the budget for said committee shall be
recommended by the committee itself for approval by the
finance committee of WVSMA. Be it further

RESOLVED, that said committee shall be charged with
the following:

1. Research and/or study the current GME policies of
WVSMA; and

2. Research and/or study the current GME policies of
AMA; and

412 THE WEST VIRGINIA MEDICAL JOURNAL

3- Research and/or study the current GME needs of
West Virginia; and

4. Report to WVSMA on its findings at all Council meetings;
and

5. Create and adopt policy that opposes medical school
admission limitations or controls based on a perceived,
though as yet unproven, physician surplus; and

6. Create and adopt policy that favors positive
incentives and educational programs that encourage
entrance to primary care fields; and

7. Create and adopt policy which firmly opposes
arbitrary' percentage mechanisms for reaching
physician workforce targets.

Resolution No. 7: (substitute resolution adopted)

WHEREAS, the State of West Virginia endured 43
spousal murders in family violence in 1993,

WHEREAS, in 1992, the United States Surgeon General
ranked abuse by husbands and partners as the leading
cause of bodily injury to women ages 15 to 24, an even
greater toll of mental anguish.

WHEREAS, 4 million women in the United States are
battered annually,

WHEREAS, week after week, there are news reports in
Appalachia of men killing their female partners and, often,
themselves,

RESOLVED, that the WVSMA support legislation that
provides adequate funding for victims of domestic violence,
provides stronger laws shielding victims of domestic
violence, provides increased policy training regarding
prevention of domestic violence, forbids domestic violence
offenders and stalkers from owning guns and subjects
domestic violence offenders to mandatory jail terms.

Resolution No. 8: (not adopted)

WHEREAS, The health care costs associated with
tobacco use are well documented; and

WHEREAS, Tobacco prices are subsidized by all
taxpayers in the form of tobacco price supports requiring
non-tobacco users to help pay for these health care cost;
therefore be it

RESOLVED, That the WVSMA support legislation seeking
elimination of tobacco price supports.

(Fiscal Note: No significant impact.)

(It is current WVSMA policy to support the AMA ’s
compendium regarding tobacco which includes this
legislation .)

Resolution No. 9: (substitute resolution adopted)

WHEREAS, There is increasing evidence that secondary
smoke is a hazard to the health of those who inhale it
(particularly children) in enclosed environments; and

WHEREAS, AMA policies 490.972, 490.982, 490.990,
505.978, 505.979, 505.983 and 505.994 strongly encourage
the elimination of smoking in the workplace, restaurants,
ballparks, etc; and

WHEREAS, McDonald’s recently banned smoking in its
restaurants; therefore be it

RESOLVED, That the WVSMA encourage its membership
to initiate or join anti-tobacco coalitions in their community.
(Fiscal Note: No significant impact.)

Resolution No. 10: (substitute resolution adopted
as amended)

WHEREAS, Pressure from managed care would limit
access by excluding physicians from caring for their
patients, because of financial contractual obligations,
therefore be it,

RESOLVED, that no participating PHYSICIAN be subject
to termination “without cause,” but only after an appeals
process including notice, an appropriate probationary
period, and failure of the physician to comply with
corrective action.

Resolution No. 11: (substitute resolution adopted)

WHEREAS, the majority of the State of West Virginia is
federally designated as medically underserved; and
WHEREAS, the Board of Medicine was statutorily
created to protect the public health; which health is best
served by the availability of competent doctors; and

WHEREAS, the Board of Medicine, having one of the
highest rates of discipline in the country, may be
perceived as a deterrent to the practice of medicine in
West Virginia; and

WHEREAS, it is the perception of some physicians that
the procedures, conduct, decisions and sanctions of the
Board of Medicine are not always fair and equitable in
light of the allegations of misconduct; therefore be it

RESOLVED, that the WVSMA Executive Committee
appoint a committee to study the procedures, conduct,
decisions, and actions of the Board of Medicine, to
improve communications with the Board, and to report to,
and make recommendations concerning the Board to the
WVSMA on a regular basis.

Resolution No. 12: (substitute resolution adopted)

WHEREAS, 20/40 best corrected vision is required for
the privilege of obtaining an unrestricted driver’s license in
West Virginia,

RESOLVED, that WVSMA support legislation to require
appropriate vision testing for renewal of a driver’s license.

Resolution No. 13: (substitute resolution adopted)

WHEREAS, the incidence of tobacco use among our
youth is increasing, and

WHEREAS, the tobacco industry makes millions of
dollars in profits in illegal tobacco sales to our youth, and

WHEREAS, as a result of political contributions from
these profits, the tobacco industry has suppressed
legislation that would limit the availability of tobacco to
youth, and

WHEREAS, the AMA House of Delegates passed
Resolution 424 sponsored by the WVSMA that states that
the AMA encourage state and local medical societies to
determine whether the candidates for federal, state and
local offices accept gifts or contributions of any kind from
the tobacco industry, and publicize their findings to both
their members and the public, therefore be it

RESOLVED, that the WVSMA submit to the AMA House
of Delegates at the Interim-94 Meeting a resolution that the
AMA determine whether candidates for federal office
accept gifts or contributions from the tobacco industry and
publicize their findings to their members and the public.

OCTOBER 1994, VOL. 90 413

Annual Meeting 1994

Annual Reports

Committee on Cancer

The members of the Committee on Cancer met for their

1993 annual meeting at The Greenbrier during the
WVSMA’s 1993 Annual Meeting.

The first order of business was an update on the second
year of the grant for the Breast and Cervical Cancer
Screening Program presented by Nancye Bazzle, program
director of the Cancer Control Program for the West
Virginia Bureau of Public Health. She reported that a total
of 42,000 mammograms had been performed and 156 cases
had received follow-ups, resulting in the diagnosis of 13
cases of cancer. In addition, a total of 11,000 pap smears
were performed with 141 colposcopy procedures, and
three of these cases had cervical cancer. Bazzle stated that
there were 120 screening facilities in West Virginia and that
their goal was to have private practice physicians be
included as screening providers. She also reported that
there are 41 mammography facilities accredited by the
ACR in the state.

Patricia Hilton Wilbur, professional education
coordinator for the Mary Babb Randolph Cancer Center’s
Breast and Cervical Cancer Screening Program, reported
that the Bureau of Public Health provides continuing
education and educational materials to cytotechnologists,
pathologists, nurses, radiologic technologists and other
health care professionals. She added that more information
can be obtained by contacting Cancer Information Services
at 1-800-4-CANCER. The committee members then
recommended having the information concerning the
professional education component of the Breast and Cervical
Cancer Screening Program published in the WESGRAM.

Beverly Keener, cancer surveillance coordinator for the
Bureau of Public Health, commented that 6l hospitals
reported cancer cases, 14 of which have tumor registries. A
exchange data agreement was ongoing with Virginia,
Pennsylvania and Maryland, and the 1994 approved funding
for the Cancer Registry was $186,000. The administrative
rules of the West Virginia Cancer Registry were to be
presented at the fall legislative session. The members of
the committee then recommended that any release of
information be made only to the reciprocal states.

The meeting concluded after Dr. Mendoza, the
committee chairman, announced details about the Fall
Cancer Conference and the committee’s next meeting at
the WVSMA’s Mid-Winter Clinical Conference. ( This
meeting was later canceled due to hazardous road
conditions.)

The committee’s next meeting was held on August 19,

1994 at The Greenbrier. After a review of the correspondence
which the committee had been involved with during the
past year, Patricia Hilton Wilbur presented a report on the
Public Health Nurses Physical Assessment Training
Sessions, which were conducted in Charleston in
December 1993- She also discussed the CME programs
which had been televised by MDTV during the past year,
and announced that two CME conferences had been
scheduled for 1995. These workshops will be "Fine Needle
Aspiration for Primary Care" on April 29, and "Primary
Care Perspectives on Women 's Health. ” which will be held
this winter.

In addition, Wilbur stated that screening information for
various cancer-related topics are available through PDQ.
Physicians can access this service by calling the Cancer
Information Service at 1 -800-4-CANCER by FAX machine or
through Internet. Two new developments that are now
available are a physician reminder system with a distribution
of reminder “Cancer Screening” cards, and a computer
software program named “Check-Up,” for recording cancer
screenings.

The next speaker was Beverly Keener, who reported that
in 1994 there were 17 hospitals in West Virginia involved
in the Cancer Registry with plans for more to be added. An
application for the 1995 funding of the Cancer Registry was
submitted in the amount of $236,706. She also announced
that Dr. Slemp, an epidemiologist, would be joining the
West Virginia Department of Health and Human Resources
and that the software for hospital cancer registries is
available. A summary of diagnosed cancer patients in West
Virginia a total of 7,084 cases from 1981 to August 15, 1994
(3,283 males and 3,802 females). The most frequent
histologies were adenocarcinoma and squamous cell
carcinoma, and the most frequent sites were the lung and
bronchus, breast, prostate gland, colon, cervix insitu,
urinary bladder, and the rectum and rectosigmoid.

Dr. Mendoza stated that goals and recommendations
had been set forth to classify the staging of cancer TNM at
the meeting of the Cancer Liaison Physicians of the American
College of Surgeons Commission on Cancer, which had
been conducted at The Greenbrier on May 5.

The meeting was concluded after the members sent a
recommendation to the Executive Committee that they
would not meet at the WVSMA’s Mid-Winter Clinical
Conference unless an issuue needed to be acted upon.
Their next meeting is scheduled for The Greenbrier in
August 1995, on the same day that the Cancer Coalition of
West Virginia will be meeting.

Council

The November 14, 1993, meeting of the Council
addressed the following items:

— The 1994 budget was approved. A report on the
WVSMA and WESPAC was discussed, and the
WVSMAA president delivered a report.

— The financing of the activities of the Medical
Education Committee were discussed in light of the
increased demand on this group in accrediting various
organizations in the state, and the guidelines
established by F.D.A. addressing CME.

— The Health Care Provider Tax Act and the difficulties
in obtaining information from the Medicaid office
were described, ft was decided that a final decision
on whether the WVSMA will institute a lawsuit against
the tax would be made at the Council’s January meeting.

— An update on the BC/BS liquidation was presented, ft
was estimated that when this action is completed,
physicians with claims will receive 50 cents on the
dollar, rather than the 8-12 cents initially anticipated.

414 THE WEST VIRGINIA MEDICAL JOURNAL

At the meeting on January 23, these items were addressed:

— The Council affirmed the decision to proceed with the
litigation concerning the Medicaid provider tax. The
suit was to be filed in the next few weeks, and a
press release was to be distributed at the time of the
filing.

— The legislative program of the WVSMA was discussed
and it was endorsed by Council.

— The 1993 financial report was given as approved.

The following items were on the agenda at the Council
meeting on April 17:

— The 1994 first quarter financial statement was approved
after it was reviewed and the new format was discussed.

— A representative from the AMA explained why WVSMA's
delegate representation had dropped from 4 to 3-

— The major issues in the Medicaid litigation were
discussed by the WVSMA’s attorney. These included
the 2% tax, the 30% reduction in payments, and the
management of the Medicaid office.

— An update on the BC/BS liquidation was given by the
WVSMA’s attorney. At that time, the WVSMA had
spent $89,535 to protect the interests of all physicians
involved in this issue.

— A review of the legislative session was presented and
it was reported that the health reform bill by
Governor Caperton had not been passed.

— The makeup and purpose of Primary One, Inc., a
managed care program consisting of primary care
physicians throughout the state was given.

— Action was taken to establish a $500 fee for the
annual review of accredited CME sponsors. This
action was made due to the increased requirements
for maintaining these programs.

The August 17 meeting addressed the following topics:

— Dr. Markey’s recommendation that Mutual Assurance
of Alabama, Inc., which does business as Medical
Assurance of West Virginia, Inc., be endorsed by the
WVSMA as the organization’s medical malpractice
insurer. After a brief presentation and question and
answer session, this recommendation was passed by
the members.

— The financial report was reviewed and approved. A
membership update was also given which showed that
the total numbers were the same for 1993 and 1994.

— A review of the status of the Medicaid litigation was
given, as well as an update on the BC/BS liquidation.

Committee on
Medical Education

The WVSMA is recognized as a provider to accredit
intrastate continuing medical education programs by
authorization through the Accreditation Council for
Continuing Medical Education (ACCME). WVSMA has
maintained this role since 1972.

Interest has been expressed in accreditation for
sponsorship of CME programs by the following: Bluefield
Regional Medical Center, Bluefield; Black Lung Clinic and
Primary Care & Recruitment, Charleston; Monongahela
General Hospital, Morgantown; Ohio Valley Medical Center,

Wheeling; and Wetzel County Hospital, New Martinsville.
According to procedure, preliminary questionnaires and
information on Essentials and Standards for Commercial
Support have been sent to these organizations and
hospitals interested in establishing Continuing Medical
Education accredited programs.

The nine organizations that have been resurveyed and
the one interim report that has been submitted since the
last Annual Report are as follows:

Mid-Ohio Valley Continuing Medical Education

Survey: September 8. 1993

Surveyors: Lester Labus. MD; Nancie Diwens; and
Shirleen Lipscomb

Award: Continued four-year accreditation with six-month
report and two-year interim progress report.

Monongahela Valley Association of Health Centers
(Fairmont Clinic)

Survey: September 15, 1993

Surveyors: James Helsley, MD; Nancie Diwens; and
Shirleen Lipscomb

Award: Four-year accreditation with two-year interim
progress report.

United Hospital Center, Inc.

Survey: September 16, 1993

Surveyors: Anne Hooper, MD; Nancie Diwens; and
Donna Webb

Award: Four-year accreditation with six-month report.

Fairmont General Hospital

Survey: February' 25, 1994

Surveyors: James D. Helsley, MD; Nancie Diwens; and
Shirleen Lipscomb

Award: Full four-year accreditation with annual reports

Pleasant Valley Hospital

Survey: February 22, 1994

Surveyors: Frederick Spencer, MD; Nancie Diwens; and
Shirleen Lipscomb

Award: Full four-year accreditation with annual reports

Reynolds Memorial Hospital, Inc.

Survey: March 4, 1994

Surveyors: Terry Elliott, MD; Nancie Diwens; and
Shirleen Lipscomb

Award: Full four-year accreditation with annual reports

Jackson General Hospital

Survey: April 7, 1994

Surveyors: Frederick Spencer, MD; Nancie Diwens; and
Shirleen Lipscomb

Award: One-year probation with assistance from WVSMA
staff

St. Francis Hospital

Survey: April 25, 1994

Surveyors: Daniel S. Foster, MD; Nancie Diwens; and
Shirleen Lipscomb

Award: Continued full four-year accreditation with
annual reports

American Heart Association-WV Affiliate

Survey: May 10, 1994

Surveyors: Ron Stollings, MD; Nancie Diwens; and
Shirleen Lipscomb
Award: Four-year accreditation

WV Academy of Otolaryngology, Head and Neck
Surgery, Inc.

One-year interim report submitted

OCTOBER 1994, VOL. 90 415

WVSMA currently has these 21 institutions/organizations
accredited for Category 1 credit of the Physician’s
Recognition Award of the American Medical Association:

American Heart Association
Affiliate, Charleston, WV

Beckley Appalachian Regional WV Hospital
Beckley, WV

Broaddus Hospital/Myers Clinic
Philippi, WV

Charleston Area Medical Center
Charleston, WV

City Hospital
Martinsburg, WV

Davis Memorial Hospital
Elkins, WV

Fairmont General Hospital
Fairmont, WV

Jackson General Hospital
Ripley, WV

Mid-Ohio Valley CME
Parkersburg, WV

Monongahela Valley Assoc, of Health Centers
(Fairmont Clinic)

Fairmont, WV

Pleasant Valley Hospital
Point Pleasant, WV

Raleigh County Medical Society
CME Program, Beckley, WV

Reynolds Memorial Hospital
Glen Dale, WV

St. Francis Hospital
Charleston, WV

St. Mary's Hospita
Huntington, WV

United Hospital Center, Inc
Clarksburg, WV

VA Medical Center
Martinsburg, WV

Weirton Medical Center
Weirton, WV

WV Academy of Ophthalmology
Charleston, WV

WV Academy of Otolaryngology
Charleston, WV

Wheeling Area CME Program
Wheeling, WV

The Committee continues to monitor each organization’s
compliance with the Essentials and Guidelines and the
Standards for Commercial Support set by ACCME. The
CME Accreditation Director attends all site visits with the
survey teams as a source of continuity and uniformity in
the application of standards for institutions/organizations.

WVSMA received and distributed the MD Anderson
publication on Preparing Objectives for CME Activities to
all intrastate sponsors accredited by our program. This was
done as a result of the number of inquiries from CME
coordinators requesting information/assistance in writing
objectives.

A video tape series was ordered from the Alliance for
Continuing Medical Education entitled “ Continuing
Education in Health Care. ” This educational series consists
of eight video modules and a workbook. The videos
provide important information about how to access
individual learning needs and learning styles; increase the
relevance of group activities to individual and organizational
learning styles; increase the relevance of group activities to
individual and organizational learning needs; make
learning activities integral to, and a critical component in,
improving health care; apply the seven ACCME Essentials;
and find and match available resources with identified
needs. This series will be extremely helpful in surveyor
training.

A CME Workshop, "CME: Paradigms of the Future , ’’was
held May 19, 1994, at the Robert C. Byrd Health Sciences
Center of WVU in Charleston. Guest speakers were
Frances Maitland, ACME Executive Director; Michael I.
Gannon, AMA; David Lichtenauer, a CME consultant;

Robin Rector, CAMC CME; David Bailey, MU CME; Kari
Long, WVLI CME; and physician members of the WVSMA,
Drs. James L. Comerci, James E. Brick, John W. Traubert,
and James D. Helsley. Several WVSMA staff members
attended for educational purposes as well as to facilitate
the registration and record-keeping pertinent to the
workshop. The panel participation and Q & A which
followed was well received. Another workshop is planned
for May 18, 1995.

The Executive Committee and Council reviewed and
unanimously approved an updated version of the Policies
and Procedures and CME Mission Statement during their
Executive and Council meeting in April.

WVSMA’s CME Accreditation Program was resurveyed
by the ACCME on July 16, 1994, and we should be notified
of the results in October. Robert L. Tupper, M.D.,
Committee for Review and Recognition, and Judith G.
Clark, Ph D., Director of CME, Florida Medical Association,
were the site surveyors. WVSMA’s Committee on Medical
Education met during the survey.

Nancie Diwens and Shirleen Lipscomb attended the
1994 ACCME Accreditation Workshop, August 12-13 in
Williamsburg, Va. In addition, Dr. Traubert and Nancie
Diwens both attended the State Medical Society-ACCME
Conference in Chicago, 111., September 9-10, 1994.

416 THE WEST VIRGINIA MEDICAL JOURNAL

FERRELL P H 0 T 0 G R A P H I C S

Specializing in public relations and advertising
photography for the health care industry

1116 Smith Street Suite 217 Charleston, WV 25301 Phone: (304) 340=4254

Scientific Newsfront

Alzheimer’s disease: A new hope

M. KHALID HASAN, M.D., F.A.P.A., F.R.C.P. (C)
Diplomate, American Board of Psychiatry and
Neurology; and Medical Director, Department
of Psychiatry, Beckley Appalachian Regional
Hospital, Beckley

DEBRA MOONEY, M.S.N., R.N., CS

Certified Family Nurse Practitioner, Certified
Clinical Nurse Specialist, Raleigh Psychiatric
Services, Inc., Beckley

Abstract

Until recently, the diagnosis and
treatment of Alzheimer’s disease
was limited. This article describes
the outcome of new research and
advances in the pharmacological
treatment of this disease, especially
the use of Cognex (tacrine). It also
reports on a multicenter study of
tacrine we participated in with
patients at Raleigh Psychiatric
Services, Inc. in Beckley.

Introduction

In a recent study of 5,000 men and
women, it was shown that memory
loss over a period of 35 years is
common, but by no means inevitable.
The rate of memory decline varies for
men and women, with the greatest loss
being in basic math for both sexes, and
the least in spatial orientation for men
and inductive reasoning in women (1,2).

However, in Alzheimer’s disease
there is progressive loss in memory,
intellect, attention, orientation, visual-
spatial function and problem solving
(3,4). Deterioration, though variable,
usually occurs in a stepladder fashion;
things learned last are the first to be
forgotten.

Even though diagnosed clinically, a
definitive diagnosis of Alzheimer’s can
be made only by brain biopsy.
However, with a multidisciplinary
approach CT, MRI, lumbar puncture,
EEG, and psychological testing such
as the Mini-Mental State Examination,
Bender, Blessed Dementia Scale and
the Clock Test, this disease can be
diagnosed with 90% clinical accuracy
(3). There are no known biological
markers to diagnose Alzheimer’s, but
in September 1993, a skin culturing

test for detecting it was first described
(5). In addition, many scientists believe
that the hippocampus is the first area
affected by Alzheimer’s since there is
an excess atrophy which can be
detected early in an expert
neuroradiological exam on either CT or
MRI.

It is estimated that 9% of the
individuals over 65 and 10% of the
population over 75 suffer from
Alzheimer’s (5,6). This disease accounts
for 55%-60% of all the dementias, and
is possibly related to an autosomal
dominant genetic inheritance (6), with
mutations on chromosome 21, 21q or
4lq (in early onset) and on
chromosome 19 (in late onset) (7,8).

The role of Apo E

The role of Amyloid and Amyloid
Precursor Protein, enriched in neurons,
is critical in the development of
Alzheimer’s, though the mechanism is
not clearly defined (6,9,10). Apo E,
involved in mobilization and
redistribution of cholesterol, transfers
amyloid to the brain where it
accumulates extracellularly in the
amyloid plaque; intracellularly in the
neurofibrillary tangles, forming deposits
that strangle nerve synapses (5,8).

Present in chromosome 19, Apo E is
found in three genetic variants as E2
(2%), E3 (78%), and E4 (15%)

(7,11,12, 13,14). Normally, the Apo E3
allele is inherited by 90% of the
population, and 60% inherit two copies
of the allele. More than half of the
individuals who develop Alzheimer’s
inherit the E4 allele.

Roses, Strittmatter and Salvensen at
Duke University studied 234 individuals
in 46 families and found the following:

1. If Apo E4 is inherited from both
parents, the chance of developing
Alzheimer’s by age 68 is increased
nine times.

2. If Apo E4 is inherited from one
parent, the chance of developing
Alheimer’s at age 77 is increased
three times.

3. If no Apo E4 is inherited, the
average age of onset of Alzheimer’s
is 85 years.

This study estimated that 2% of the
population falls into the high risk
category, E4/E4, and 64% into the E4
category ( 12,13,14). It further supports
that position that Alzheimer’s is a
syndrome with various subtypes of
varying etiology with considerable
overlap.

As such subtypes emerge over the
next decade, specific behavioral,
psychosocial and phannacological
interventions to target each subtype
will need to be developed. The new
hope for Alzheimer’s victims is that
future research may focus on the
development of drugs which will short
circuit the process in which Apo E4
affects the neurofibrillary plaques and
tangles. Early diagnosis and preventive
treatment may be offered through
blood tests designed to identify Apo E4
carriers.

Pharmacological treatment

Although disappointing in the past,
pharmacological treatment of
Alzheimer's is proving to have some
effectiveness. Drugs such as lecithin,
hydergine, ACE inhibitors, piracetam
( nootropic), and tacrine (aminoacridine),
may modestly improve cognition
function and slow the progression of
the disease though they do not reverse
the course (15).

To evaluate the effectiveness and
potential hepatotoxicity of tacrine in
the treatment of dementia of the
Alzheimer’s type, we participated in a
multicenter study with patients at
Raleigh Psychiatric Services, Inc. This
study was conducted from the summer
of 1992 until November 1993, when
this drug was released by the FDA.

Initially, during our early clinical
trials, tacrine was not as effective in the
treatment of Alzheimer’s as was
expected. Further clinical experience,
however, indicated that this drug is
more effective if doses greater than 80
mg./day given for at least 160 days, are
taken either alone or in combination
with other drugs such as eldepryl. We
have found tacrine effective in
approximately 25%-40% of the patients
receiving the drug.

418 THE WEST VIRGINIA MEDICAL JOURNAL

Currently, all our patients at Raleigh
Psychiatric Services, Inc. are
administered the Mini-Mental Status
Examination and Clock Test prior to
starting on tacrine. These tests are
repeated periodically to assess any
objective, cognitive improvement,
which is coordinated with the subjective
reporting by the caregivers, the latter
being more important. A CT scan, EEG,
MRI, and other tests are also conducted
prior to prescribing this medication in
order to rule out an organic basis of the
dementia. Alzheimer’s patients and
families are informed of the risks and
benefits of the drug prior to initiation,
so the decision to start the drug is
collective.

Tacrine must be carefully monitored.
Most common side effects are transitory
and include GI disturbance (anorexia,
diarrhea), lowered seizure threshold,
psychomotor agitation, and increased
ALT levels as a sign of liver involvement.
Through use of home health nurses,
weekly ALT levels for the first 18 weeks
should be performed, even as the
dosage is increased, from 40 mg./day
to a maximum of 160 mg./day at six-
week intervals. When ALT levels are
greater than three to five times the
upper limit, the tacrine dose is
decreased by one capsule (10-40
mg./day) depending on the dosage
being administered. After the ALT
returns to normal limits, the dosage
may again be titrated upwards, though
more slowly. Once a patient is
stabilized on an adequate dosage
(80-160 mg./day), monitoring ALT
levels is left to the discretion of the
physician usually at intervals of every
month to three months.

Sudden stoppage of tacrine should
be avoided since it may result in rapid
mental deterioration and may simulate
stupor or even cerebrovascular
accident. During the clinical trials,
patients who were hospitalized and
taken off tacrine suddenly became
confused, incoherent and lethargic.

When tacrine was reinstituted, the
patient returned to their previous level
of functioning.

In our experience, initial agitation,
w'hich may cause concern in families,
has been found to be a positive,
prognostic indicator that the families
should be forewarned of and the drug
should not be stopped as a result.
Depending on the clinical needs of the
patient, improvement may be made
through a judicious combination of
antidepressants (preferably SSRI),
antipsychotics or short-acting
anxiolytic. Conventional antipsychotics
are not well tolerated and, we have
found that in selected cases, small
doses of Risperidone or Clozapine can
be fairly effective and well tolerated.

Conclusion

The current research and
phannacological treatment of
Alzheimer’s does not promise a cure or
panacea of treatment, however, it can
give new hope for families and victims
of this disease by slowing its progress.
Future research to identify various
subtypes and developing those specific
treatment modalities and prevention,
such as those suggested by Schiae (1),
offer a new hope for the population at
large, especially those at high risk (i.e.,
the aged with a positive F/H).

The characteristics outlined by
Schaie for predicting a person’s mental
function as they age are as follows:

1. A high level of ability in reading
comprehension or verbal fluency.

2. A successful career or some other
active involvement through life and
continuing keen mental interests
after retirement.

3. Having a flexible attitude in middle
age is also a promising indicator --
less mental decline in people who
adapt easily to change, i.e. those
who like new learning and enjoy
going to new places.

4. Simply living with someone with
the characteristics mentioned in the
first three items is beneficial over
the course of long marriages.
Spouses' scores on mental abilities
tend to converge, with the brighter
partner elevating the other’s score.

References

1 . Schaie KW. The course of adult intellectual
development. American Psychologist 1994,
April;304-13.

2. Kintsch W. Text comprehension, memory,
and learning. American Psychologist 1994,
April:294-303.

3. Friedland RP. Alzheimer’s disease: clinical
features and differential diagnosis. Neurology
1993;43:45-31.

4. Cummings JL, Benson DF. Dementia: a
clinical approach. Boston: Butterworth
Heineman, 1992:1-548.

5. Davis KL, Haroutunian V. Strategies for the
treatment of Alzheimer’s disease. Neurology
1993;43:52-5.

6. Longenecker RG. Update: progress in the
diagnosis and treatment of Alzheimer’s
disease. Spectrum 1991:141-7.

7. Rosenberg R. A casual role for amyloid in
Alzheimer's disease: the end of the
beginning. 1993 American Academy of
Neurology Presidential Address. Neurology
1993;43:851-6.

8. Schellenberg G, Bird T, Wijsman E, et al.
Genetic linkage evidence for familial
Alzheimer’s disease locus on chromosome
14. Science 1992;258:668-71.

9. Strittmatter W, Saunders A, Smechel D, et al.
Apolipoprotein E: high affinity binding to
beta-amyloid and increased frequency of
type-4 allele in late-onset familial Alzheimer’s.
Proc Natl Acac Scie USA 1993;90:1977-81.

10. Poirier J, Davignon J, Bouthillier D, et al
Apolipoprotein E polymorphism and
Aizheimer’s disease. Lancet 1993;342:697-9.

11. Corder EH. Saunders AM, Strittmatter WJ, et al.
Gene dose of apolipoprotein E type 4 allele
and the risk of Alzheimer’s disease in late
onset families. Science 1993;261:921-3.

12. Verher F, Jolles J, Ponds R, et al. Diagnosing
dementia: a comparison between a
monodisciplinary and multidisciplinary
approach. J Neuropsych 1993;5:78-85.

13- Gottlieb GL, Kumar A. Conventional

pharmacologic treatment for patients with
Alzheimer’s disease. Neurology 1993;43:56-63.

14. Croisile B, Trillet M, Fondarai J, et al. Long-
term and high-dose priacetam treatment of
Alzheimer’s disease. Neurology 1993;43:301-4.

OCTOBER 1994, VOL. 90 419

A post-thyroidectomy convulsion: An unusual
presentation of chronic hypoparathyroidism

JOAN B. LEHMANN, M.D.

Department of Family and Community
Health. Marshall University School of
Medicine. Huntington

JOHN W. LEIDYJR., M.D., Ph.D.

Medical Service. Veterans Administration
Medical Center. Huntington

Abstract

A 59-year-old woman with
previously undiagnosed
hypoparathyroidism presented with
a tonic-clonic seizure 38 years after
thyroidectomy. This case is unusual
because of the initial presentation,
but also unique because it is the
longest latency period between
surgery and presentation in recent
literature.

Introduction

Convulsive disorders are common
among the general population, affecting
as many as 2 million Americans during
their lifetimes (1). However, there are
many medical conditions in addition
to epilepsy which may present with
seizures, such as tumors, endocrine
disorders, and substance abuse and
withdrawal.

When a patient presents directly
with a new onset seizure, a complete
history and physical, as well as basic
laboratory testing should be performed.
This includes electrolytes, calcium,
magnesium, phosphorous, and, if
appropriate, drug screening. This
testing will prove immediately valuable
in the diagnosis and treatment of any
patient’s underlying cause of seizure,
and in the patient’s case we will be
describing, showed chronic
hypoparathyroidism.

Adult hypoparathyroidism is most
commonly iatrogenic, secondary to
surgery involving the thyroid or
parathyroid glands (2). The damage to
the gland or to the vascular supply
lowers serum levels of parathyroid
hormone and calcium with secondary
changes in magnesium and
phosphorous (3). The hypocalcemia
may be manifested as changes in
neuromuscular excitability or as
irritability of the central nervous
system. This condition can present
years after thyroid or neck surgery.

In this article, we describe a patient
with hypoparathyroidism who initially

presented with a single tonic-clonic
seizure, 38 years after thyroidectomy.
This case was unusual because of its
initial presentation, but also unique
because it is the longest latency
period between surgery and
presentation in recent literature.

Case report

A 59-year-old woman arrived at the
Emergency Department at the Veterans
Administration Medical Center in
Huntington with complaints of nausea,
several bouts of vomiting and diarrhea,
shortness of breath and weakness
over the previous three days. Her
medical history included hypertension
for which she had been treated for
eight years, gout, and a history of
alcohol abuse, which had become
progressively worse over the past few
years. She did state, though, that for
the two weeks prior she had not
consumed any alcohol, and also had
never gone through alcohol
withdrawal, and had never experienced
a previous seizure.

This patient had undergone a
thyroidectomy for treatment of toxic
goiter 38 years previously. Her
medications included allopurinol,
diltiazem, levothyroxine, and
triamterene/hydrochlorothiazide.

On physical examination, her vital
signs were temperature 100.5 F, pulse
119, respirations 20, and blood
pressure 146/97. She was oriented but
lethargic. There was no apparent
injury to the head; the fundi were not
seen due to mild cataracts. Her neck
was supple with a thin transverse scar;
lungs were clear to auscultation. In
addition, her abdominal exam and
neurological exams were normal, and
her deep tendon reflexes were hypo-
reflexive in all four limbs.

A complete chemistry panel and a
complete blood count were ordered.
While this patient was in the Radiology
Department for a chest X-ray, she
experienced a single brief tonic-clonic
seizure. When she was returned to the
Emergency Department, she was
immediately given a loading dose of
intravenous phenytoin and additional
tests (drug screen and magnesium,
calcium, phosphorus and serum
alcohol levels) were ordered.

Initial laboratory results were:
sodium 136, potassium 4.2, chloride
98, bicarbonate 25, BUN 8.0, creatinine

0.8 and glucose 122. Serum calcium
was 4.8 (8.5-10.5 mg./dl.), phosphorous
was 6.8 (2. 5-4. 5 mg./dl.) and magnesium
was 2.0 (1.7-2. 4 mg./dl.). Urinalysis
was within normal limits. Albumin
was 2.9, LDH 544, SGOT 164, GGT
534, alkaline phosphatase 195 (30-100
U/l); values which can be explained
by the patient’s previous alcohol use
and poor nutritional intake.

Her complete blood count was
WBC 10.1, with a normal differential;
hemoglobin 13-8. Thyroid function tests
showed TSH 4.4 (0.3 - 5.0 mlU/mh),
T4 4.9 (4.5 - 12.0 pg./dl.), free
thyroxine index 1.42 (0.99 - 4.08), T3
uptake 29 (21 - 34%), which were all
within normal limits. Toxicology
screen showed no recent use of
barbiturates, benzodiazepines or
tricyclics, and her serum alcohol level
was was zero.

The results of this patient’s EKG
showed a sinus tachycardia rate of
110, normal QT interval 0.36. Her
chest X-ray revealed no infiltrates of
the lungs and normal heart size. A CT
scan of the head without contrast
showed no evidence of ischemia,
bleeding or mass effect. Further
studies after admission showed urine
calcium 68 mg./24 hr. (100-300 mg./24
hr.), parathyroid hormone C-terminal
< 0.3 ng./ml. (significantly below
normal) with a simultaneous serum
calcium of 6.3 mg./dl.

Immediately after the serum calcium
level was reported, the presumptive
diagnosis was hypoparathyroidism,
and the patient was treated with a
10% solution of calcium gluconate at
5.5 ml. /hr., magnesium sulfate, 1.0 g.
IV over 15 minutes, and aluminum
hydroxide by mouth. After initial
therapy and 14 hours after admission,
an EEG was performed which showed
non-specific generalized slowing of
waves. Phenytoin was continued
during her hospital stay until the
serum calcium reached acceptable
levels to prevent further seizure activity.

She had no other seizures during her
admission and was successfully
controlled with calcium carbonate 1 .0 g.
(elemental calcium) tid, magnesium
chloride hexahydrate 130 mg. tid,
aluminum hydroxide 3 g- tid (all by
mouth) and was discharged on the
fifth hospital day. Vitamin D analogs
were not given because the seaim
calcium was stable at 7.3 mg./dl. at

420 THE WEST VIRGINIA MEDICAL JOURNAL

discharge, and further management of
hypocalcemia was to be completed as
an outpatient.

Discussion

This case report is unusual for two
reasons: the prolonged latency from
the time of surgery to development of
hypoparathyroidism and the
presentation with seizures.

Dimich and colleagues reported
their experiences with adult
hypoparathyroidism in 21 patients, 16
of whom presented with symptoms of
hypoparathyroidism within one year
of surgery. The remaining five presented
between one and 19 years after
surgery (4). In addition, Petch
described a case that presented 27
years postsurgery (5), and Blancharde
reported a case which presented 33
years after thyroidectomy (6). Our
patient had undergone her
thyroidectomy in 1953 for toxic goiter,
and presented with hypoparathyroidism
38 years after surgery, so her latency
period is the longest cited in recent
literature.

Usually, hypoparathyroidism
presents in adults initially as muscle
spasms, carpopedal spasms and facial
grimacing. In the experience of
Dimich et al, the most common
presenting symptom is carpopedal
spasm (4). Only 4% of patients with
postoperative hypoparathyroidism
present with convulsions, compared
to 70% of patients with idiopathic
hypoparathyroidism (4).

Due to her history of alcohol abuse,
it was initially assumed that this
patient was suffering from withdrawal

(“rum fit”), which may first present as
a brief, single generalized tonic-clonic
seizure. However, this is unlikely since
she and family members reported that
she had consumed no alcohol for at
least two weeks.

This patient's complaints of
weakness and lethargy are attributable
to hypoparathyroidism. She also had
coarse, dry skin and hair which are
often found in hypothyroidism (even
though she was receiving thyroid
replacement and her thyroid function
tests were nonnal), but which are also
described in hypoparathyroidism.
Another of her symptoms was
diarrhea, which is a common finding
in hypoparathyroidism (7).

It is likely that this patient had
suffered from hypocalcemia for some
time. It can be speculated that a
combination of factors including acute
viral gastroenteritis, poor nutritional
intake (as evidenced by her low
serum albumin), post-menopausal
state or other factors contributed to
her severe hypocalcemia, eventually
leading to her convulsion. Studies by
Endres have shown that dietary
calcium intake decreases in the
elderly and that elderly women have
elevated urinary calcium excretion,
which is presumably related to
reduced levels of estrogens after
menopause (8).

When an adult presents with an
initial seizure, it is important that a full
evaluation be completed. The
diagnosis of hypoparathyroidism
should be considered in all patients
with a thyroidectomy scar. Convulsions
caused by hypocalcemia may be fully

corrected by treating the underlying
cause, without long-term
anticonvulsant therapy (3,9).

Acknowledgment

The authors wish to thank Dr.
Christoph Lehmann for his technical
assistance.

References

1. Seizure Disorders. Fisher RS, Barker LR,
editors. In: Principles of Ambulatory Medicine.
Baltimore: Williams and Wilkins, 1990:1096-
1113.

2. Schneider AB, Sherwood LM. Pathogenesis
and management of hypoparathyroidism
and other hypocalcemic disorders. Metabolism
1975; 24:871-98.

3. Potts JT. Diseases of the parathyroid gland
and other hyper- and hypocalcemic disorders.
In: Braunwald E, et al, editors. Harrison's
principles of internal medicine. New York:
McGraw Hill, 1987, (2)1870-89.

4. Dimich A, et al. Hypoparathyroidism:
clinical observation in 34 patients. Archives
of Internal Medicine 1967;120:449-58.

5. Petch CP. Hypoparathyroidism presenting
with convulsions twenty-seven years after
thyroidectomy. Lancet 1963;2:124.

6. Blancharde BM. Focal hypocalcemic
seizures 33 years after thyroidectomy.
Archives of Internal Medicine 1962;110:382-5.

7. Moshkowitz A, et al. Congenital
hypoparathyroidism simulating epilepsy,
with other symptoms and dental signs of
intra-uterine hypocalcemia. Pediatrics 1969;
44:401-9.

8. Endres DB, et al. Age related changes in
serum immunoreactive parathyroid
hormone and its biological action in
healthy men and women. J of Clinical
Endocrinology and Metabolism 1987;65:
724-31.

9. Gupta MM, Grover DN. Hypocalcemia and
convulsions. Postgrad Med J 1977;53:330-3.

Manuscript Guidelines

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They must be prepared in accordance with “Uniform
Requirements for Manuscripts Submitted to Biomedical
Journals. "

All manuscripts should include:

1. Title page

2. An abstract of no more than 150 words

3. Text

4. Acknowledgements

5. References in parentheses numbered consecutively. No
more than 25 references will be published free of charge.

6. Tables

7. Legends for illustrations

All persons designated as authors should qualify for
authorship. Each author should have participated sufficiently
in the work to take public responsibility for the concept.

Where reference is made to generically-designated drugs,
the first such reference must be followed by parentheses
containing its most commonly known trade name.

All scientific material is reviewed by the Publication
Committee and should be sent to The Editor, West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.

OCTOBER 1994, VOL. 90 421

Medical Grand Rounds

Robert C. Byrd Health Sciences Center of WVU

Edited by Irma H. Ullrich, M.D., Professor of Medicine, Section of Endocrinology and Metabolism

Hantavirus Pulmonary Syndrome

DISCUSSANT: R. WESLEY FARR, M.D.

Section of Infectious Diseases, Department of
Medicine, West Virginia University School of
Medicine, Robert C Byrd Health Sciences
Center of WVU, Morgantown

Abstract

An outbreak of Hantavirus
Pulmonary > Syndrome ( HPS )
occurred in the ivesterti U.S. in 1993-
This outbreak was surprising
because serious disease due to
hantavirus had not been reported
previously in the U.S., and hantavirus
had not been documented to cause
significant pulmonary disease.
Epidemiologic investigation
discovered a novel strain of
hantavirus as the etiologic agent of
HPS. The Centers for Disease Control
( CDC) proposed the name of Muerto
Canyon virus for this novel
hantavirus, which is transmitted
through aerosolized excreta of
infected rodents. HPS begins with a
prodrome of fever, myalgia, and
respiratory > symptoms followed by
the acute onset of respiratory >
distress. Since HPS has a mortality
of 60%, early recognition is
important so that supportive
treatment can be initiated promptly.
Intravenous ribavirin is
investigational therapy and can be
obtained through the CDC in Atlanta.

Introduction

The Hantavirus Pulmonary
Syndrome (HPS) (1-4) was one of
several emerging infectious diseases
that posed significant challenges for
the U.S. medical community during
1993- An outbreak of HPS, which was
centered in the Southwestern states of
New Mexico and Arizona, was
arguably the most interesting
emerging infectious disease of last
year. This HPS outbreak was the first
recognized clinical syndrome caused

by hantavirus in which significant
pulmonary disease occurred, and was
the first documented outbreak of
significant human disease due to
hantavirus in the United States.

This paper presents an overview of
the 1993 I IPS outbreak and discusses
the epidemiology and the very rapid
and effective public health response.

It also reviews previously known
clinical syndromes associated with
hantavirus and emphasizes the clinical
manifestations, treatment, and
prevention for this disease.

The 1993 HPS outbreak

The initial cluster of cases of HPS
was recognized and reported by Dr.

B. Tempest who was working for the
Indian Health Service. He reported
that on 5/5/93, a 19-year-old healthy
male Navajo long distance runner
died after he was brought to Gallup
Indian Medical Center in full
cardiopulmonary arrest. This patient
had clear respiratory secretions with a
negative gram stain, and his chest
X-ray (CXR) had shown diffuse
bilateral infiltrates consistent with
adult respiratory distress syndrome.

Two days prior to this patient’s
death, the index case had been seen
in another Indian Health Service clinic.
This first patient had experienced a
respiratory illness with fever (102°),
non-productive cough, clear lungs to
auscultation, negative CXR, and
elevated serum lactic dehydrogenase
(LDH). He had been treated
empirically with erythromycin and
amantadine for two days without
improvement and then experienced
acute respiratory failure.

The first patient’s fiancee had died
from a similar illness five days prior to
his death. Microbiologic and serologic
studies were negative for Yersinia
pestis , the etiologic agent of pneumonic
plague which is endemic to the Four
Corners area (New Mexico, Arizona,
Utah, and Colorado).

Response by Public Health

Dr. Tempest’s colleagues in the
Indian Health Service informed him of
three similiar cases of an acute febrile
respiratory syndrome, so he reported
the initial cluster of cases to the New
Mexico Department of Health
(NMDOH) on 5/14/93- The NMDOH
began a site investigation on 5/17,
and serum and tissue samples were
sent to the Centers for Disease Control
(CDC) on 5/21.

CDC staff members came to
Albuquerque on 5/29, and by 6/4,
they had identified a previously
unknown hantavirus as the possible
etiology by serologic results. Their
initial report was published on 6/11
(1), and on 6/18, the CDC reported
confirmation of hantavirus as the
etiologic agent with the use of the
polymerase chain reaction (PCR) (2).
The CDC then published Interim
Recommendations for Risk Reduction
on 7/30 to prevent further cases of
HPS (5).

By the end of 1993, the CDC had
identified 53 persons with confirmed
cases of HPS (4). A majority of these
cases were young adults, 57% were
male, and 49% were American Indians
(Table 1) (4). The cases occurred in
residents of the 14 states west of the
Mississippi River (Figure 1) (4), and
some of the confirmed cases occurred
prior to 1993 (Figure 2) (4). The
mortality rate for HPS was 60% (4).

Hantavirus syndromes

Hantaviruses are RNA viruses that
belong to the Bunyaviridae family.
Other genera of the Bunyaviridae
family include bunyaviruses which
cause California encephalitis,
phleboviruses which cause Rift Valley
fever, and nairoviruses which cause
Congo-Crimean hemorrhagic fever.
The routes of transmission for these
three genera of Bunyaviridae are
insect bites.

422 THE WEST VIRGINIA MEDICAL JOURNAL

Table 1. Characteristics of the 53 persons in the U.S. reported with hantavirus pulmonary
syndrome from May - December 1993

Deaths

Characteristic

Total

No.

(%)

Relative risk

(95% CD)

Age (yrs.)

<20

(57)

Referent

20-29

(50)

0.9

(0.4-2. 0)

30-39

(78)

1.4

(0. 4-2.0)

>40

(50)

0.9

(0.4-2. 0)

Sex

Female

(57)

Referent

Male

(63)

1.1

(0. 7-1.8)

Race

American

Indian

(58)

Referent

Other t

(63)

1.1

(0.7-1. 7)

* Confidence interval.

I Non-hispanic white, Hispanic, and non-Hispanic black.
Source: CDC. MMWR 1994;43:45.

Figure 1. Number of reported confirmed cases of hantavirus pulmonary syndrome -
United States, 1993

Source: CDC. MMWR 1994;43:46.

In contrast, transmission of
hantaviruses does not require or
utilize insects, but involves rodent
reservoirs and aerosolized or airborne
rodent excreta. Hantavirus causes
asymptomatic infection in the rodent
reservoir but serious disease in the
human host.

Hemorrhagic fever with RS

Hemorrhagic fever with renal
syndrome (HFRS) is the only previously
described clinical syndrome caused by
hantavirus (6-9). HFRS was initially
described as Korean Hemorrhagic Fever
(KHF) when caused by the Hantaan
virus or the Seoul virus in Korea, or
nephrotica epidemica when caused by
the Puumala virus in Europe (7).

Korean Hemorrhagic Fever

KHF is a viral infection acquired from
rodents in Asia north of the Himalayas
in Korea, Eastern Siberia, and China,
which can cause severe disease
manifested by shock and renal failure
with a 10% mortality (6-8). KHF mostly
affects rural civilians and military
personnel stationed in rural areas, and
there are 100,000 cases per year in
China (9).

This disease was first reported in
the 1930s by Russians in Far Eastern
Siberia, and then it affected Japanese
military personnel during the
Manchurian campaign of World War II,
and 3,000 U.S. troops during the
Korean War (7). From I960 to 1990,
there were less than 10 cases per year
in American troops in Korea except for
an outbreak of 14 cases during a
training exercise in 1986 (10).

The etiologic agent of KHF was
isolated in 1978 near the Hantaan river
in South Korea (11). The World Health
Organization adopted the terminology
of Hemorrhagic Fever with Renal
Syndrome (HFRS) in 1982 for both KHF
and nephrotica epidemica, the similar
syndrome occurring in Europe (7).

The clinical manifestations of HFRS
occur in five stages (6-8). The first or
febrile stage begins with the abrupt
onset of fever, chills, lethargy, and an
erythematous flush of the head, neck,
and trunk. During days 3-5, petechiae,
hemorrhage, progressive leucocytosis,
and proteinuria appear.

The second or shock stage begins
on day 5 with hypotension, proteinuria,
and thrombocytopenia of less than
70,000/cu mm. This stage is the most
serious and requires intense supportive
care in order to prevent fatalities.

During the third or oliguric phase, the
patient recovers from hypotension and

experiences normotension or
hypertension. Oliguria then occurs,
resulting in a rapid rise in BUN,
hyperkalemia, hyperphosphatemia,
and hypocalcemia. Hemorrhagic
manifestations, such as gross
hematuria, subconjunctival
hemorrhage, hemoptysis, and
gastrointestinal bleeding also appear,
and some patients experience central
nervous system manifestations
including restlessness, hallucinations
and seizures. Pulmonary manifestations
are infrequent and insignificant.

The fourth or polyuric phase occurs
during days 7 to 10 when diuresis
signals improvement and the

complications resolve. Convalescence
occurs during the fifth phase.

Epidemiologic studies of KHF in
American military personnel
demonstrated that the troops at risk
slept near high grass and scrub brush.
These troops would be most likely to
be exposed to the aerosolized rodent
excreta.

Hantavirus infection in the U.S.

Acute renal or pulmonary
manifestations of human hantavirus
infection in the United States had not
been described prior to the 1993 HPS
outbreak, but hantavirus infection in

OCTOBER 1994, VOL. 90 423

Figure 2. Number of confirmed cases of hantavirus pulmonary syndrome, by month and
year of onset and by state — July 1990 - December 1993*

12
11 H
10
9
8

v> 7

O 5
4
3
2
1
0

0 Residents of Arizona, Colorado, or New Mexico
I Residents of Other States

J ASOND
1990

J FMAMJ JASON DJ FMAMJ J ASOND J FMAMJ J ASOND

1991

1992

1993

Month/Year of Onset

* Does not include one case from 1980 reported in California.

Source: CDC. MMWR 1994;43:46.

American rodent populations had been
well documented (12-17), as well as
cases of infection without illness (18,19).

In West Virginia, there have been
cases of both hantavirus infection in
the state’s rodent population (16,17),
and in our residents (18). In addition,
a recent report found that 6.5% of
patients in Baltimore with hypertensive
renal disease but no prior history of
HFRS were seropositive for hantavirus
compared to a seroprevalence of
0.25% for the reference group (20).

Hantavirus Pulmonary Syndrome

A NMDOH toxicologist noted a
major infestation of mice during the
site visit to the index patient’s home
during the outbreak in New Mexico in
May 1993. Serologic studies showed that
the primary reservoir for the 1993 HPS
outbreak was the deer mouse,
Peromyscus maniculatis (3). Other
rodents with serologic evidence of the
New Mexico strain of hantavirus
include the pirion mouse, P. truei; the
brush mouse, P. boylii; and western
chipmunks, Tamias species (3).

Transmission of HPS to humans
occurs primarily by inhalation of
aerosols of rodent saliva or excreta, or
by the ingestion of contaminated food
or water; rarely is there direct
inoculation onto broken skin or
conjunctiva, or is it transmitted by
rodent bites. In the New Mexico site
visit, no illness was observed in the
rodent hosts, and there was no
evidence of human to human
transmission.

Molecular epidemiology

By serologic evaluation, the New
Mexico strain of hantavirus was most
closely related to the Prospect Hill strain
of hantavirus and less closely related
to the Seoul, Hantaan, and Puumala
viruses (3). The Prospect Hill strain
has been found in the native rodent
population of the forested areas
around Frederick, Md. (12), and nucleic
acid sequencing studies confirmed
that the New Mexico strain was most
similar to the Prospect Hill strain (21).

The Muerto Canyon virus has been
proposed as the name for the New
Mexico, or Four Corners, strain of
hantavirus which causes HPS (4).

Clinical manifestations

During the New Mexico outbreak,
CDC officials established screening
criteria for HPS as part of their
epidemiologic investigation (3). One
set of inclusion criteria included a
febrile illness (temp > 101 F (38.3 C))

in a previously healthy person with
unexplained adult respiratory distress
syndrome or bilateral interstitial
infiltrates with a requirement for
supplemental oxygen. An alternative
set of inclusion criteria included an
unexplained fatal respiratory illness
with autopsy findings of noncardiogenic
pulmonary edema.

Exclusion criteria for HPS were a
predisposing medical condition, such
as malignancy, immunodeficiency,
immunosuppressive therapy, or severe
pulmonary disease, and an acute illness
that is a likely etiology for ARDS, such
as trauma, seizures or aspiration, sepsis,
respiratory syncytial virus (RSV),
influenza, or legionellosis (3).
Confirmation of HPS had to be made
with at least one specimen (serum and/
or tissue) available for lab testing and
one of the following three tests positive
for hantavirus: serology (detectable
IgM or rise in IgG), polymerase chain
reaction (PCR) for RNA, or
immunochemistry for antigen (3).

The patients in New Mexico had a
prodrome of fever, myalgia, and
respiratory symptoms followed by an
abrupt onset of acute respiratory
distress (3). Other symptoms included
headache, abdominal pain, nausea, and
vomiting. Laboratory abnormalities
included hemoconcentration in 76% of
the cases which progressed during the
period of hospitalization;
thrombocytopenia in 71%; and
leucocytosis with an increase in bands,

hypoalbuminemia, and lactic acidosis (3).
All patients developed bilateral
pulmonary infiltrates within two days of
admission, and gross pathology
revealed serous pulmonary effusions
and heavy edematous lungs (3).

Microscopic examination
demonstrated interstitial infiltrates of
mononuclear cells in alveolar septa,
congestion, and septal and alveolar
edema (3). Cellular debris and
neutrophils were not prominent.
Immunohistochemistry detected
hantavirus antigen in the endothelial
cells of most organs with heavy
accumulations in the lungs (3).

Treatment

Treatment of HPS involves mainly
supportive care with supplemental
oxygen, fluid management, and
vasopressor agents or cardiotonic
drugs (3). Caution should be taken to
avoid overhydration (3).

Intravenous ribavirin has been shown
to be effective in hantavirus FIFRS (22)
and is investigational in HPS (3). It can
be obtained by phoning the CDC
Ribavirin Officer of the Day on
weekdays at 404-639-1510 and on
weekends/evenings at 404-639-2888 (3).

Prevention

The prevention of HPS depends
upon the realization that hantavirus
infections in humans occur primarily
in adults who become exposed to

424 THE WEST VIRGINIA MEDICAL JOURNAL

rodent excreta during domestic,
occupational, or leisure activities (5).
Some of the activities that place
people at risk include planting or
harvesting field crops, occupying
previously vacant cabins or other
dwellings, disturbing rodent-infested
areas while hiking or camping, and
residing in areas in which rodent
populations have shown an increase
in density (5).

Specific recommendations for risk
reduction through environmental
hygiene practices have been
described by the CDC (5).

Summary

An outbreak of HPS occurred in the
western United States in 1993- This
outbreak was the first reported
outbreak of serious disease due to

I hantavirus in the United States and the
first occurrence of significant
pulmonary disease due to hantavirus.
The etiologic agent of HPS is a novel
strain of hantavirus with the proposed
name of Muerto Canyon virus.

HPS is transmitted through
aerosolized excreta of infected rodents
and the symptoms of this disease
include fever, myalgia, and respiratory
symptoms followed by the acute onset
of respiratory' distress. Treatment is
mainly supportive, but intravenous
ribavirin is being investigated and can
be obtained through the CDC. There
is a 60% mortality rate.

Prevention of HPS involves
reducing exposure to rodent excreta
in persons whose occupational,
domestic, or leisure activities place
them at risk.

References

1 . CDC. Outbreak of acute illness - southwestern
United States, 1993. MMWR 1993;42:421-4.

2. CDC. Update: outbreak of hantavirus
infection - southwestern United States, 1993.
MMWR 1993;42:441-3.

3. CDC. Update: hantavirus pulmonary
syndrome - United States, 1993- MMWR 1993;
42:816-20.

4. CDC. Hantavirus pulmonary syndrome -
United States, 1993. MMWR 1993;43:45-8.

5. CDC. Hantavirus infection - southwestern
United States: interim recommendations for
risk reduction. MMWR 1993:42 (No. RR-11):
M3.

6. Sheedy JA, Froeb HF, Batson HA, et al. The
clinical course of epidemic hemorrhagic
fever. AmJ Med 1954;16:619-28.

7. Lee HW. Korean hemorrhagic fever. Prog
Med Virol 1982;28:96-113.

8. McKee KT, MacDonald C, LeDuc JW, Peters
CJ. Hemorrhagic fever with renal syndrome -
a clinical perspective. Milit Med 1985;12:
640-7.

9. Chen HX, Qiu FX, Dong BJ, et al.
Epidemiological studies on hemorrhagic
fever with renal syndrome in China. J Infect
Dis 1986;154:394-8.

10. Lee HW, Lee PW, Johnson KM. Isolation of
the etiologic agent of Korean hemorrhagic
fever. J Infect Dis 1978:137:298-308.

11. CDC. Korean hemorrhagic fever. MMWR
1988:37:87-90,95-6.

12. Lee PW, Amyx HL, Yanagihara R, Gajdusek
DC, Goldgaber D, Gibbs CJ Jr. Partial
characterization of Prospect Hill virus
isolated from meadow voles in the United
States. J Infect Dis 1985;152:826-9.

13. Yanagihara R. Hantavirus infection in the
United States: epizootiology and
epidemiology. Rev Infect Dis 1990;12:449-57.

14. LeDuc JW, Smith GA, Johnson KM.
Hantaan-like viruses from domestic rats
captured in the United States. Am J Trop
Med Hyg 1984;33:992-8.

15. Tsai TF, Bauer SP, Sasso DR, et al. Serologic
and virological evidence of a Hantaan
virus-related enzootic in the United States. J
Infect Dis 1985;152:1260-36.

16. Yanagihara R, Daum CA, Lee P-W, et al.
Serologic survey of Prospect Hill virus
infection in indigenous wild rodents in the
United States. Trans R Soc Trop Med Hyg
1987;81:42-5.

17. Baek LJ, Yanagihara R, Gibbs CJ Jr.,

Miyazaki M, Gajdusek DC. Leakey virus: a
new hantavirus isolated from Mus musculus
in the United States. J Gen Virol 1988;69:
3129-32.

18. Yanagihara R, Chin C-T, Weiss MB, et al.
Serologic evidence of Hantaan virus
infection in the United States. Am J Trop
Med Hyg 1985;34:396-9.

19. Childs JE, Glass, Korch GW, et al. Evidence
of human infection with a rat-associated
Hantavirus in Baltimore, Maryland. Am J
Epidemiol 1988;127:875-8.

20. Glass GE, Watson AJ, LeDuc JW, Kelen GD,
Quinn TC, Childs JE. Infection with ratbome
hantavirus in U.S. residents is consistently
associated with hypertensive renal disease.

J Infect Dis 1993;167:614-20.

21. Hjelle B, Jenison S, Torrez-Martinez N, et al.
A novel hantavirus associated with an
outbreak of fatal respiratory disease in the
southwestern United States: evolutionary
relationships to known hantaviruses. J Virol
1994;68:592-6.

22. Huggins JW, Hsiang CM, Cosgriff TM, et al.
Prospective double-blind, concurrent,
placebo-controlled clinical trial of intravenous
ribavirin therapy of hemorrhagic fever with
renal syndrome. J Infect Dis 1991;164:1119-27.

John D. Holloway, M.D.

Internal Medicine/Vascular Medicine
(certified by the American Board of Internal Medicine)

is pleased to announce the relocation of his practice to:

Valley Professional Center
2115 Chapline Street, Suite 305
Wheeling, WV

in association with Rick A. Greco, D.O.

phone: 234-8361
fax: 234-1838

OCTOBER 1994, VOL. 90 425

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know about

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Strength.

Stability.

Involvement.

Commitment.

These are the four watchwords that
the WVSMA Council lived by as we
considered potential choices for our
professional liability endorsement. In
the end, only Medical Assurance of
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First and foremost, Medical
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President's Page

Choose wisely

Through Medical Assurance, we will
be able to participate in, and indeed
be protected by, the stability born of
careful, thoughtful growth.

We closely examined Medical
Assurance/Mutual Assurance’s
philosophies and found them to be
congruent with those of the
physicians in out state. Mutual
Assurance has more than 17 years
experience in professional liability
insurance and has demonstrated to us
the need for the involvement of
West Virginia physicians in their
program. Our representatives have
attended meetings of Mutual
Assurance’s Claims and Underwriting
Committees, and have seen them put
into action their philosophy of
physician involvement. There is a
strong bond to organized medicine,
and we will be asking many of you to
serve in various capacities to help
insure that this program mirrors your
needs and desires.

No relationship is built without a
solid foundation. In this case, the final
cornerstone of the foundation is
Medical Assurance’s long-term
commitment to you, the WVSMA,
and to the goals we have set forth for
ourselves.

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premiums increased dramatically.
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to guarantee the company’s long-term
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Dennis M. Burton, M.D.

428 THE WEST VIRGINIA MEDICAL JOURNAL

Editorial

Politics and Medicine

If Medicine has ever been the
recipient of strong encouragement to
be politically active, that encouragement
has been received this year. Oh yes,
we have had AMPAC and the various
state pacs in the past and some of us
have actually contributed time and
money to efforts stirred by such as
these. It seems obvious, however, that
a significant majority of us have never
been convinced that the expense and
effort would be in anyway availing,
even though the stated aims and goals
were undeniably attractive.

One might be inclined to attribute
this gift of encouragement to the
Clintons who certainly catapulted the
profession into what has been a life or
death struggle. The real revelations,
however, seem to be the allies we
have discovered — allies willing to go
to the mat in defense of those things
we have held dear but feared others
might not appreciate. It is undeniable
now — we do have political power
and it is possible for us to set and to
reach political goals. But these efforts
need to be made in conjunction with
friendly allies.

One hardly needs to point out that
in the process of all this we have
assumed the obligation to examine at
least some of the issues that might be
important to our new found friends.

In that regard, it has always been
surprising to note the number of
physicians in this state registered and
voting Democratic. We have heard the
time honored argument in explanation
of this phenomenon that if you want
to have any effect at all on the political
process in West Virginia, you must
vector things within the Democratic
party because of the impotence of the
Republican party in this state. It seems
to us, however, that such an argument
simply perpetuates a very unfortunate
and very undesirable condition at the
ballot box which makes it virtually
impossible in many cases to remove
elected officials badly in need of
being removed. Besides that, it is
certainly clear that our intra-Democratic
party efforts have gotten us precious
little other than contempt from our
Democratic legislators in years gone by.

One also might note that physicians
as a group generally identify themselves
as religiously inclined or, at least,
God-fearing and church-going
individuals. In this capacity, we are
maligned along with all others identified
as members of the “religious right,” a
designation connoting certain
intolerant, perhaps fascistic tendencies.
'Right Wing” is an epithet bestowed
by our liberal media on any
organization or group refusing to toe

the politically correct line they
trumpet. Nowhere on the American
political scene are there any
identifiable groups to be categorized
as “left wing,” who turn out to be
merely “liberal.”

Religious individuals and groups
stirred to political action have quite
appropriately raised the issue of
“Family Values.” Incredibly, the
Clintons have attempted to steal that
issue and now trumpet what is
apparently their version of family
values. This is an absolute absurdity in
the hands of the morally degenerate
Clintons, yet their alienation from any
value system based on morals is so
complete that they do not appreciate
the absurdity. It is not possible for
anyone who possesses a system of
moral values to even consider
supporting the Clintons or any others
allowing themselves to be identified
with them.

For starters, American physicians
along with people of any moral
persuasion have every reason to break
all ties with anyone associated with
the Clintons. West Virginia physicians
in particular have reason to break all
ties with the Democratic party.

- Stephen D. Ward, M.D.

OCTOBER 1994, VOL. 90 429

In My Opinion

Medical care - A tale of four countries

The United States has the best health care system in the
world — PERIOD. It is the envy of medical professionals
in all other countries. It is the medical mecca, the best
place to be if you are seriously ill. Despite this, it is the
subject of criticism based on indices such as infant
mortality, life expectancy, etc., that really represent
radically different lifestyles, manipulation of statistics, and
ethnic differences rather than the strengths or weaknesses
of the health care system.

President Clinton points out that we spend 14% of our
gross national product on health care, compared to 9% in
Germany and Japan. He says their health outcomes are
equal or better than ours. Very well, let’s look at Japan,
Germany and Sweden.

JAPAN - Japan has the lowest infant mortality rate; the
U.S. ranks 24th among 39 developed countries. The
difference is in definitions. A “live birth” in the U.S. may
be a stillbirth in Japan. Births between 20 and 27 weeks
gestation are “live births” in the U.S., but stillbirths in
Japan and many countries. Our infant mortality rate is 9 2
per 1 ,000 live births, less than 1%. For low birthweight
infants, say those at 1,000 grams (2.2 lbs.) or less, the
mortality rate may be 50%-80%. We try to save these
infants with neonatal ICUs. Other countries dump them in
the trashcan or incinerator as stillbirths Is this what we
want?

The Japanese doctor is paid $4 per established patient,
$13 for a new patient. To make ends meet, he has to have
high volume — an average of 64 patients per day, less than
five minutes each. Is this what we want? Patients receiving
pelvic exams are lined up, several in the same room
assembly line style. Is this what we want?

Japan has extremely high stomach cancer rates, very low
rates of breast cancer, myocardial infarction, and
hypertension, reflecting ethnic differences, not the health
care system itself. Their deaths from cerebrovascular
disease are twice the U.S. rate. In summary, there is no
evidence we need to copy the Japanese model.

GERMANY - I lived in West Germany from 1967 to
1970 as a commanding officer serving in the 16th Medical
Detachment in Crailsheim. The biggest complaint I heard
from German doctors at the time was that the system
allowed patients to receive six weeks at a health spa on
regular prescription from their doctor. The German word
“bad” means “bath.” The towns of Bad Canstatt, Bad
Mergentheim, Bad Tolz, Bad Wimpfen, etc., possess springs
with allegedly curative properties. If you hurt anywhere
below the nares, you could dangle your body in these
waters at government expense. The benefit has been cut
to two weeks, but is an example of health benefits
prescribed by the political system.

The Germans have four to five times our automobile
fatality rate. No mystery here; many parts of the autobahn
have no speed limit. The cars and roads are built for

speeds of 120-150 miles per hour and this is the rule, not
the exception. You can be driving 130 miles per hour and
be passed by a Porsche doing 150 miles per hour. As one
German friend told me, “On the autobahn, there are no
non-fatal accidents.” A typical accident may cause
$200,000 damage to vehicles, kill six to eight people, and
the cost to the medical system is zero; no survivors. If this
is what we want, we will have to redesign both roads and
cars. In addition, the Germans have a higher mortality rate
for myocardial infarction, twice the mortality rate for
strokes, more than twice the rate for epilepsy, and three
times the rate for prostate disease.

SWEDEN - Sweden was formerly the leader in infant
mortality. Closer inspection of their figures, in addition to
the comments already made about Japan, reveals several
things. In the U.S., infant mortality is reported by hospitals.
In Sweden, it is the parents’ responsibility and they have
five years to report a case of infant mortality — with no
penalty for non-reporting. If the aggrieved parents do not
report it, or if they are unaware of the differences between
a live birth, a stillbirth, an abortion, etc., who is hurt? — the
U.S., by having to compete with these figures.

In the U.S., the infant mortality is highest among blacks.
It turns out that this is not a socioeconomic problem, but
an ethnic one. College-educated, middle-class blacks have
the same problem. If we excluded blacks, perhaps we
would be number one. Preposterous, you say. The Swedes
have no blacks, but they have Lapps, whom they exclude
from their statistics. To the Swedes, the fact that the Lapps
have resided in northern Sweden for two millennia does
not make them Swedish. In the U.S., we include blacks,
whites, orientals, native Americans, all comers.

Finally, research articles from Scandinavia talk about a
97%-98% patient follow-up. Since Sweden has a socialized
system, missing a doctor’s appointment is against the law.
Miss one and you may attend the next in handcuffs. Miss
two in a row and the police cannot find you. Regular
prenatal checkups can reduce infant mortality, but we
have never made the decision to have a police state
enforce this, as Sweden does. Is this what we want?

The message here is clear. We have the best health care
system in the world. The best always cost more, but may
be well worth it. Critics of the U.S. system use phony
statistics to cast the U.S. in a bad light — exploiting
differences in definitions, lifestyles, and ethnic characteristics —
not differences between medical care systems. The
purveyors of these lies are not organizing planeloads of
pregnant women to take them to Japan or Sweden for
delivery. Any future actions at the federal level to totally
revamp our system have the capability of destroying this
premier position — an act of political self-mutilation.

Wallace D. Johnson, M.D.

Beckley

430 THE WEST VIRGINIA MEDICAL JOURNAL

Letter to the Editor

Medical Assurance: By and for physicians

West Virginia physicians have a
new partner. With the WVSMA's
endorsement of Medical Assurance of
West Virginia, Inc., West Virginia
physicians finally can enjoy the
protection offered by a West Virginia
based, A+ (Superior) rated malpractice
insurer. Physicians will have a
committed, involved partner in
Medical Assurance, and its parent
company, Mutual Assurance, Inc.,
which has more than $500 million in
assets and a long history of physician
participation in its operations.

Mutual Assurance is one of the
strongest physician-founded malpractice
companies in America, and the story
of the company’s success explains a
great deal of the excitement
surrounding the partnership they seek
to build with West Virginia’s
physicians. That story, in excerpts
from a recollection written by the now
deceased founding chairman, Dr. C. A.
Lightcap, is as follows:

Mutual Assurance was forged in the
fire of crisis.

The physicians on the Alabama
Medical Association Insurance
Committee thought we had worked out
a durable insurance solution when
Employers of Wausau agreed to cover

Alabama physicians for five years. But
in October 1975 , severe losses forced
Wausau to get out of the malpractice
business. We were given until August
1977 to find another carrier.

We contacted 60 insurance
companies, but received not one
favorable reply. We turned to other
state associations and heard horror
stories, but found no solutions. Slowly
at first, then with increasing speed, the
concept of a doctor mutual company
began to take shape.

Necessity, then, was Mutual
Assurance’s mother and we only
assisted in the delivery ; the baby would
be bom with or without us.

There were times when we wayited to
quit — we’re physicians not
underwriters — but the malpractice
climate did not give us the luxury of
that choice.

Mutual Assurance was incorporated
on October 1, 1976, and within seven
months, more than 2,000 Alabama
physicians enrolled. As the malpractice
storm grew in intensity, Mutual
Assu rance and its policyholders
weathered it through sound financial
management arid a commitment to
defense.

Mutual Assurance began with
physicians involved at every step and
that tradition continues with
physicians participating in the claims
and underwriting process, and serving
in the majority of seats on the MA
Board of Directors. The company
utilizes Regional Advisory Boards to
stay in close touch with its
policyholders and maintains a close
liaison with its sponsoring medical
associations.

Physician involvement is a key part
of the foundation upon which Mutual
Assurance has built its success, and
West Virginia physicians will be called
upon to be just as active in the
operations of Medical Assurance. The
WVSMA is excited about the
commitment Mutual Assurance brings
to West Virginia with Medical
Assurance. The leadership of the
WVSMA urges you to carefully
evaluate the safety and security
offered by Medical Assurance. You
can rest assured that your interests
will be well protected.

A. Derrill Crowe, M.D.

President

Medical Assurance of
West Virginia, Inc.

OCTOBER 1994, VOL. 90 431

Interactions

Medical Staff Leadership Conference — January 13-15, San Antonio, Texas

Health system reform might seem like a never-ending battle,
but with leadership, vision, and perseverance, you and your
medical staff can overcome any obstacle. Leam what it takes
to succeed in today’s rapidly changing environment. Come to
Interactions in beautiful San Antonio, Texas, January 13-15.

Experience a new way of thinking
about the future.

This year’s conference, “Physician Empowerment and
Teamwork in a Changing Environment,” will help you
experience a change of perspective on the 21st Century.

Learn how to manage change.

During Interactions, we will address emerging trends in
health care delivery and how best to manage them. Among
the trends we will discuss are:

• Physician/hospital • Physician autonomy

relationships • Resource allocation

• Economic competition • Regulatory constraints

Gain new leadership skills.

Special emphasis will also be placed on developing and
refining your strategic planning, team building, and com-

munication skills. Each participant will learn how to be a
more effective arbitrator, facilitator, manager, negotiator,
problem solver, and peacemaker.

Your team leaders.

Sponsored by the American Medical Association, in cooper-
ation with the National Association Medical Staff Services
and the Texas Medical Association, this conference features
well known experts from the health care field.

Who should attend.

The curriculum is designed to benefit experienced and newly
elected or appointed medical staff leaders, including: chiefs
of staff, department chairs, vice presidents of medical affairs,
medical staff committee chairs, and medical staff services
professionals* Bring a team from your hospital!

For more information or to register, call 800 621-8335.

* The AMA designates the Interactions conference for 18
credit hours of Category 1 of the Physician’s Recognition
Award of the AMA.

American Medical Association

Physicians dedicated to the health of America

SUCCESSFUL

MONEY

MANAGEMENT

Another Member Benefit From Your Association!

Areas of Discussion!

• 1993 Tax Law Overview

- Summary of the new Tax Law

- New Opportunities in tax planning

• Estate Planning

- The probate process

- Wills, Trusts, Estate Taxes

• Equity/Fixed Income Investments

- Stocks, Bonds, Ltd Partnerships

- Purchasing strategies, Asset allocation

• Retirement Planning

- Qualified Pensions (SEP's, 401 K, 403B)

- Select Benefit Plans

Registration Fee $250.00
Spouse Fee $125.00

Seminars Consist of Three Sessions
6:00 PM - 9:30 PM

Lite Meal Sewed

Beckley Area

Wednesday
October 26th

Charleston Area

Wednesdays

November 2nd, 9th & 16th

Fayette County

Thursdays

December 1st, 8th & 15th

Spouse’s fee waived if registered 10 days before start of seminar.

If you would like to have a special seminar done in your area, notify
the Medical Association. We will be happy to accommodate you.

□ Beckley Area

October 1994

□ Charleston Area

November 1994

□ Fayette County

December 1994

Reserve Your Place!

Don’t Wait!!!

Remember, spousal fee is waived if reservations are confirmed 10 days prior to the seminar date,
Return this self-addressed card, or call the WVSMA at (304) 925-0342.

Please Call Today!!!

Name

Spouse’s Name If Attending

Address

City State Zip

Phone Office

At Mid-Winter

Entertainment to include performance by
Dr. Neri, karaoke sing along, dance music

By popular demand, Dr. Florencio
“Jun” Neri will again present a special
musical variety show at this year’s
WVSMA Mid-Winter Clinical Conference
on Saturday evening, January 21 at the
Radisson Hotel in Huntington. In
addition to the concert and slide show
which Dr. Neri has planned, Dr. Rano
Bofill of Man will again have his laser
karaoke machine available so guests
can perform their favorite songs.

Dr. Neri, a general practice physician
in Princeton, is a native of the
Philippines who is well known by his
colleagues for his singing abilities. He
has performed at many state and
county medical meetings, as well as at
weddings, benefit concerts and other
local events. Dr. Neri is currently the
president of the Philippine Medical
Association of West Virginia.

Dr. Bofill, who is also a native of
the Philippines, is a radiologist for
Roane General Hospital in Spencer.

He and his family reside in Man,
where he has been singing since 1985
at nursing homes and medical
meetings. A couple of years ago, he
purchased a laser karaoke machine
which he has been transporting with
him to a variety of events. He recently
took his “sing along show" on the
road to Boston for the annual meeting
of the Filipino American Association

Dr. Jun Neri performs a song by Elvis
Presley at last year’s WVSMA Mid-Winter
Clinical Conference.

of Family Physicians, and to Richmond
for the annual meeting of the Virginia
Association of Filipino Physicians.

"I am very pleased to again be able
to offer the karaoke show to the
members and guests attending the
WVSMA’s Mid-Winter Conference,” Dr.
Bofill said. “In the past year I have
added many new discs to my collection,
so I now have Spanish and gospel
recordings available as well as rock n'
roll, country, popular, and children’s

Dr. Rano Bofill will again be
bringing his laser karaoke
show for meeting participants.

music. I will be offering trophies for
the best solo, best duet and best
group performances. In addition, I will
play a wide variety of dance music,
such as the limbo, tango and electric
slide during the breaks in the singing,”
he added.

This special evening of entertainment
is being presented in conjunction with
a reception by Acordia of West Virginia
and Medical Assurance of West
Virginia, Inc. The reception will begin
at 7 p.m., and then Dr. Neri will
perform at 8 p.m., followed by Dr.
Bofill's karaoke show.

State awarded grant for tobacco prevention program

West Virginia is one of nine states
recently awarded a $1 million grant
from the Robert Wood Johnson
Foundation to implement a SmokeLess
States Program, which is aimed at
reducing and preventing tobacco use
among youth.

The grant was awarded to the West
Virginia Hospital Association’s
educational affiliate, the West Virginia
Hospital Research and Education
Foundation (WVHREF). Implementation
of the Smokeless States Program will
be coordinated through the West

Virginia Tobacco Control Coalition, an
advisory group to the Bureau of
Public Health.

Funding for the four-year project
began in August. Die program initiatives
are a result of a collaborative effort
between the WVHREF, the Bureau, the
American Lung Association of WV, Inc.,
the West Virginia State Medical
Association, the Mary Babb Randolph
Cancer Center and the Coalition.

Program goals include reducing the
number of children and youth who
begin using tobacco products and

reducing the number of West Virginians
who continue to smoke or use
smokeless tobacco. Other plans will
include initiatives to increase public
awareness that reducing tobacco use is
an important component to health care
reform through encouraging healthy
lifestyle costs associated with chronic
illnesses.

For more information on this new
program, contact project director
Sharon Lansdale at
(304) 347-6605.

434 THE WEST VIRGINIA MEDICAL JOURNAL

Foundation issues
call for proposals to
aid underserved

A call for proposals for a second
round of planning grants for the $14
| million REACH OUT program was
announced recently by the Robert Wood
Johnson Foundation. REACH OUT is a
major national effort to mobilize private
physicians to improve access to care
for medically underserved Americans.

In August, planning grants were
awarded to 22 private physicians’
groups in 21 communities throughout
the U.S. to develop new approaches for
delivering medical care to people who
[ currently have difficulty obtaining it.
Those grantees received development
awards up to $100,000, and based on
progress made during the first year,
they will then be eligible to receive
three-year implementation grants
averaging $200,000.

The second round will include up
to 28 additional physician-initiated
partnerships. A workshop for interested
applicants will be held on January 20,
with an application deadline of March
14. Recipients of the second round of
planning grants will be announced on
August 1.

REACH OUT is looking for
innovative models where private
physicians provide leadership to meet
the needs of people who currently have
difficulty obtaining health care. In
addition, as health insurance is
expanded through state and federal
reforms, there is a corresponding need
to organize care for those who are
newly covered.

Potential applicants should contact
the REACH OUT National Program
Office at 401-453-5120.

Forum to analyze
state’s laws concerning
incapacitated patients

"The Ethics and Law in West Virginia
of Health Care Decision Making for
Incapacitated Patients” is the subject
of the West Virginia Network of Ethics
Committees’ next forum on January 27
at the Days Inn in Flatwoods. This
meeting is designed to help West
Virginia health care professionals apply
the statutes outlined in the Medical
Power of Attorney Act, the Revised
Natural Death Act, the Health Care
Surrogate Act of 1993, and the Do Not
Resuscitate Act.

Registration for the meeting will
begin at 9:30 a.m., and then Patrick

Kelly, J.D., an attorney with Steptoe
and Johnson in Charleston, will present
a legal overview of these four statutes.
Following Kelly’s presentation, Dr.

Alvin Moss, director of the Center for
Health Ethics and Law at the Robert C.
Byrd Health Sciences Center of WVU
in Morgantown, will discuss medical
and ethical issues pertaining to these
laws. The morning session will then
conclude with a lecture on the
government’s perspective of these acts
of legislation by Charles Conroy Jr.,
director of the Office of Geriatrics and
Long Term Care of the State
Department of Health and Human
Resources.

After a break for lunch, a number of
cases will be presented to challenge
participants' abilities to apply these laws
to unique situations. A wide variety of
questions will be answered.

For more details, phone the West
Virginia Network of Ethics and Law at
(304) 293-7618.

Ophthalmology
Academy schedules
48th spring meeting

The West Virginia Academy of
Ophthalmology’s 48th Annual National
Spring Meeting will be held April 27-30
at The Greenbrier in White Sulphur
Springs.

Featured speakers for this year’s
meeting and their subjects include
John Linberg, M.D., plastic surgery;
Brooks McCuen II, M.D., retina; Philip
Shelton, M.D., J.D., managed care and
cataracts; and Thom J. Zimmerman,
M.D., Ph.D., glaucoma. The West
Virginia Academy of Ophthalmology
has designated this CME program for
12 credit hours of Category 1 of the
AMA’s Physician’s Recognition Award.

For further information, contact Pam
Stevens, conference coordinator, West
Virginia Academy of Ophthalmology,
P.O. Box 5008, Charleston, WV 25361,
(304) 343-5842 or (304) 344-8466.

Regional Hospice
conference to be held
in Charleston at UC

“ Hospice and Palliative Care ” is the
title of a regional conference which
will be presented at the University of
Charleston on November 2 and 3-
This multidisciplinary program is
sponsored by Kanawha Hospice Care
in cooperation with CAMC, and will
focus on the special needs of
terminally-ill patients and their families.

Topics include pain and symptom
management, psychosocial
interventions, family dynamics,
communication skills and spirituality.

A total of 12.5 CME credits in the
AMA’s Category 1 will be offered to
participants attending both days.
Continuing education credits will also
be provided to nurses, social workers
and counselors.

For further details, call 768-8523 or
1-800-560-8523.

Snowshoe site for
cardiology meeting

The American College of Cardiology
will present this year’s “Cardiovascular
Conference at Snowshoe” from
February 6-8 at the Mountain Lodge
Conference Center in Snowshoe.

A total of 14.5 CME credits in the
AMA’s Category 1 will be offered.

For information contact: Registration
Secretary, Extramural Programs Dept.,
American College of Cardiology, 9111
Old Georgetown Rd., Bethesda, MD
20814-1699; (800) 257-4739 (outside
the U.S. and Canada, (301) 897-2695).

NIH issues consensus
report about treating
ovarian cancer

A National Institutes of Health (NIH)
consensus development statement
entitled "Ovarian Cancer: Screening,
Treatment and Follow-up" is now
available from the NIH Office of
Medical Applications of Research
(OMAR).

For a free, single copy, contact
William Hall at (301) 496-1143.

APA offering free
booklet on depression

The American Psychiatric Association
has published a pamphlet on
depression which is free to the public.
Anyone interested in receiving a copy
may write to the American Psychiatric
Association, DPA/Dept. NB, 1400 K
Street, NW, Washington, DC 20005.

Clinical depression is one of the
most common and treatable mental
illnesses with over 10 million
Americans suffering from it in any six-
month period. Symptoms may include
a noticeable change of appetite, change
in sleeping patterns, loss of interest in
previously enjoyable activities, loss of
energy, inability to concentrate, and
recurring thoughts of death or suicide
that last for at least two weeks.

OCTOBER 1994, VOL. 90 435

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Marshall University - Huntington

November 11-13

“8th Annual Family Practice
Weekend and Sports Medicine
Conference” (sponsored by the WV
Chapter of the American Academy of
Family Physicians, the Family
Medicine Foundation of WV, the MU
Dept, of Family and Community
Health, and Jose Ricard, M.D.),
Radisson Hotel, Huntington

Robert C Byrd Health Sciences
Center of WVU - Charleston

October 22

“Laser Surgery Seminar XI”
(sponsored by The Eye and Ear
Clinic of Charleston; the Dept, of
Surgery at the Robert C. Byrd HSC of
WVU, Charleston Division; and
CAMC), Charleston Marriott

November 3

(Teleconference) “Role of Childbirth
Education: Teaching Women Active
Birth”

November 17

(Teleconference) “Evaluation of the
Worker’s Compensation Patient: IMF
and Functional Capacity
Examinations”

Robert C Byrd Health Sciences
Center of WVU - Morgantown

October 22

“Current Topics in Emergency
Medicine” (sponsored by the WVU
Dept, of Emergency Medicine),
Robert C. Byrd HSC, Morgantown*

October 27-30

“The First International Conference
on Prevention” (sponsored by The
Council of Geriatric Cardiology, The
Center for the Study of Aging, The

Lawrence Frankel Foundation, the
Robert C. Byrd Health Sciences
Center of WVU, three medical
schools of West Virginia, and Senator
Jay Rockefeller), Charleston Civic
Center, Charleston

October 28

“Fall Cancer Conference Breast
Cancer: Hie Newly Diagnosed
Patient” (sponsored by the WVU
Dept, of Medicine, Section of
Hematology/Oncology and the
MBRCC), Robert C. Byrd HSC,
Morgantown*

October 28-29

“Third Annual Appalachian Regional
Stroke Symposium” (sponsored by
the WVU Office of CME and
MountainView Regional Rehabilitation
Hospital) MountainView Reg. Rehab.
Hospital, Morgantown*

November 4-6

“The Rural Health Conference"
(sponsored by WVU Office of CME
and the Office of Rural Health
Policy), Lakeview Resort and
Conference Center, Morgantown

November 11-13

“The Art in the Science of Healing -
The 1 1th Annual Hypnosis Workshop"
(sponsored by the WVU Dept, of
Behavioral Medicine/Psychology and
the Carruth Center for Counseling
and Psychological Services), Robert
C. Byrd HSC, Morgantown

November 17

(MDTV) “Evaluation of Breast
Lumps,” Rick Hostetter, M.D.

( Participants must pre-register at their
MDTV site)

November 18-19

“OB/GYN Women’s Health
Symposium 1994” (sponsored by the
WVU Dept, of OB/GYN), Robert C.
Byrd HSC, Morgantown*

November 19

“David Zackquill Morgan, M.D. Sixth
Annual Senior Care Conference”
(sponsored by the WVU Geriatric
Program), Robert C. Byrd HSC,
Morgantown*

* Held in conjunction with a WVU
football game

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Fairmont ★ Fairmont General Hospital,
Nov. 1, 7:30 p.m. “Work Hardening,
Disability Rating, Return to Work
Criteria,” Janie Vale, M.D., M.S.P.H.

Gassaway □ Braxton County Memorial
Hospital, Oct. 26, 6:30 p.m., “Clot
Buster Update,” Harold Selinger, M.D.

Martinsburg ★ VA Medical Center,

Nov. 3, 3 p.m., “Ultrasound Update,”
Vickie Williams, M.D.

New Martinsville ★ Wetzel County
Hospital, Nov. 10, noon, “Alzheimer’s
Disease,” Robert Keefover, M.D.

Oak Hill □ Plateau Medical Center,

Oct. 25, 6:30 p.m., “Lumbar,”
Constantino Amores, M.D.

Parkersburg □ Camden Clark Hospital,
Nov. 16, noon, “Preplacement
Evaluation,” fohn Coumbis, M.D.,
M.S.P.H.

White Sulphur Springs ★

The Greenbrier Clinic, Oct. 24,

4 p.m., “Office Practice of Sports
Medicine," William Post, M.D.

Tire Greenbrier Clinic, Nov. 28,

4 p.m., “Disability Rating:
Contemporary Issues in West Virginia
Practice,” Janie Vale, M.D., M.S.P.H.

Give Yourself
Some Time.
Quit!

For more information
call toll-free
1-800-ACS-2345

AMERICAN
CANCER
? SOCIETY

436 THE WEST VIRGINIA MEDICAL JOURNAL

Poetry Corner

October

28- 29-Healthcare Quality7 Management:
Review and Study Session (sponsored by
the National Association for Healthcare
Quality), Atlanta

28-29-Clinical Innovations in Ob/Gyn
Ultrasound (sponsored by the American
Institute of Ultrasound in Medicine), New
York

November

1- 4— American Academy of Neurological
Surgery7, Sea Island, Ga.

2- 6-88th Annual Scientific Assembly of the
Southern Medical Association, Orlando, Fla.
5-9-American College of Allergy and
Immunology, San Francisco

10- 13-Annual Scientific Meeting of the
American Pain Society, Miami Beach, Fla.

11— Fifth Annual Rush Symposium on
Hepatic and Biliary Disease and Liver
Transplantation, Chicago

11- 13-8th Annual Family Practice Weekend
and Sports Medicine (sponsored by the WV
Chapter of the American Academy of Family
Physicians and the Family Medicine
Foundation), Huntington

12- 17— American Association of Blood
Banks, San Diego

13- l6-29th World Biennial Meeting of the
International College of Surgeons, London

17- 20-Consultation-Liaison Psychiatry: The
Bridge to Primary Care, Phoenix

18- 20-2nd Clinical Conference on Women's
Health in the Pathways to Change
(sponsored by the Association of
Reproductive Health Professionals), Kansas
City, Mo.

30-Physician-Based Information Systems:
Planning and Selecting Computer Systems
and Software (sponsored by the Medical
Records Institute), Washington. D.C.

December

1— Preparing for Electronic Patient Record
Systems (sponsored by the Medical Records
Institute), Washington, D.C.

2- Implementing and Managing a Health
Care Information Security Program
(sponsored by Medical Records Institute),
Washington, D.C.

For More Information . . .

Contact the Journal at (304) 925-0342.

Remembrance

Looking back along the way

he traveled through his life
and come what may
to check the depth of strife.

I remember the precept given

by that oak physician Sleeth
and follow a path once driven
in the face of grief.

The patient and the child

reflect -primo non nocere-
unlike a fancy mild
a chart of -docere-.

In a mandarin scheme
he held up the light
and etched out his theme
to put up the good fight.

John Henry McWhorter, M.D., M.P.H.

Please address your submissions for Poetry > Comer to Stephen D. Ward, M.D., Editor.
West Virginia Medical Journal P. O. Box 4106, Charleston, WV 25364.

Twg> s hoolj> help gar von't opERALE ANV HE AW MAAHlNERf.

OCTOBER 1994, VOL. 90 437

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

EMS sytem undergoing changes

West Virginia’s emergency medical services (EMS) system is
undergoing a number of changes, including the addition of a
new medical director for the program and the consolidation
of area offices that coordinate EMS activities.

Through its Office of Emergency Medical Services
(OEMS), the Bureau of Public Health oversees all statewide
EMS activities such as training and certification for EMTs and
paramedics, funding for ambulances and life support
equipment, enforcement of standards and policies, and
coordination of the EMS communications system. In addi-
tion, OEMS also provides public education on safety and
injury prevention.

John E. Prescott, M.D., F.A.C.E.P., has been named medical
director for the OEMS, replacing Frederick M. Cooley, M.D.,
who retired in June. Dr. Prescott, who is also an associate
professor and chainnan of the Department of Emergency
Medicine at the Robert C. Byrd Health Sciences Center of
WVTJ, will be working with the OEMS to provide technical
assistance and consultation to EMS agencies in the state,
medical oversight and direction to the OEMS, and assistance
to the EMS system in times of disaster or emergencies.

This spring, a legislative committee directed the Bureau
of Public Health to streamline the EMS system so that it
could be run more efficiently and effectively. The decision
was made to contract with only one area office, rather than
the two offices that had been utilized to serve as liaisons
with regional EMS offices throughout the state. After a state
review process, the Southern Emergency Medical Services,
Inc. (SEMS) was awarded a grant to provide statewide EMS
services.

A search is also underway for an administrative director
for the OEMS. For more details on the state’s EMS programs,
call Acting Director Chris Gordon at (304) 558-3956.

Enrollment in VFC program urged

The Bureau of Public Health’s Immunization Program
staff invites members of the private medical community to
enroll in the national Vaccine for Children (VFC) Program
which began October 1. The program provides enrolled
providers with vaccine for eligible children at no cost.

Currently, parents who can't afford the full series of
immunizations are referred to public health clinics, but
many county health departments have limited resources to
meet the demand for immunization services. With the VFC
Program, parents of eligible children will have the option
of having children vaccinated at a public health clinic or by
a VFC-enrolled private health care provider. Providers
should enroll in the program now to receive their first free
shipment of vaccine as soon as possible.

The VFC Program was created as part of the nation’s
Childhood Immunization Initiative to provide private
providers relief from the high costs of vaccine for needy
children. The national program can contribute approximately
$272 for every eligible child, so West Virginia children
receive the recommended vaccinations on time.

Children ages f8 and under are eligible for the program
if they meet one or more of the following conditions:

* They are enrolled in Medicaid

* They have no health insurance

* They are an American Indian or Alaska native

* They have health insurance that does not cover
vaccinations ( these children would be served by
a federally qualified health center.)

The state and national goal is to raise the percentage of
properly immunized two-year-old children to 90% by the year
f996. Currently, just over half of the state’s two-year-olds are
up-to-date on vaccinations.

For more details about the Vaccine for Children Program,
call the Bureau’s Immunization Program at (304) 558-297f
or 1-800-642-3634.

Chlamydia screenings offered

The Bureau of Public Health is joining forces with
agencies in several other mid-Atlantic states in an effort to
control the spread of chlamydia, a common sexually
transmitted disease (STD). Public health officials expect the
Chlamydia Project to prevent as many as 1,300 infections
among West Virginians alone each year, as well as serve as
a model for a nationwide chlamydia prevention effort. The
project is administered through the Bureau's STD Program,
in conjunction with its Family Planning Program and its
Office of Laboratory Services.

In September, all 181 public health STD and family
planning clinic sites in West Virginia began providing the
Chlamydia Project services to women and their partners.
These services include:

* free chlamydia testing to 40,000 women in STD and
family planning clinics each year,

* medical treatment and counseling for those women
who test positive for chlamydia and for their partner; and

* community outreach to raise public awareness of
chlamydia and the availability of the screening services.

Chlamydia is second only to the common cold as the
most prevalent infectious disease in the world. State health
officials are projecting that this new project can help prevent
an additional 1,080 cases of pelvic inflammatory disease, 33
cases of ectopic pregnancy, and 187 cases of infertility in
West Virginia each year. This would result in an estimated
annual savings of $ 1 million in health care costs.

For more details, call Robert Johnson Sr., director of the
Bureau’s STD Program, at (304) 558-2950 or 1-800-642-8244.

438 THE WEST VIRGINIA MEDICAL JOURNAL

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Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-1 6a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine's peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.

Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocon * Is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac

Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These Include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.12 Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 ■3-4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to % tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks 3
How Supplied: Oral tablets of Yocon^ 1/12 gr. 5.4 mg in
bottles of 100's NDC 53159-001-01 and 1000's NDC
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References:

1. A. Morales et al. . New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed , p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,

1983.

4. A. Morales et al. , The Journal of Urology 128
45-47, 1982.

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OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Prescott appointed
state EMS director

Dr. John Prescott,
associate professor
and chair of
emergency medicine,
has been appointed
state EMS director
by the West Virginia
Office of Emergency
Medical Services.

In this position,

Dr. Prescott will
provide assistance
and consultation to all state EMS
agencies on a part-time basis. He will
also provide medical direction to the
OEMS and assist the EMS system during
disasters and emergencies.

Ducatman elected
trustee for ABPM

Dr. Alan Ducatman,
a professor and
director of the
Institute of
Occupational and
Environmental
Health, was recently
elected a trustee of
the American Board
of Preventive
Medicine.

The ABPM accredits
physicians with public health training in
preventive, occupational or aerospace
medicine.

Murray appointed to
Halsted Society board

Dr. Gordon Murray, professor and
chair of surgery, has been named to
the board of directors of the Halsted
Society.

Dr. Murray's two-year appointment
was announced at the society's recent
meeting in Ann Arbor, Mich.

Ducatman

Prescott

Stauber speaks at
cranio-mandibular
meeting, named fellow

Ma appointed interim
assistant dean of
School of Pharmacy

William Stauber,
Ph.D., professor of
physiology and
neurology, delivered
a lecture at the
annual meeting
of the International
College of Cranio-
mandibular
Orthopedics on the
physiological basis
for TENS and non-
traditional approaches to the treatment of
cranio-mandibular dysfunction.

More than 125 dentists who specialize
in temporomandibular dysfunction,
attended the program as part of the
Eighth Bernard Jankelson Memorial
Lecture Forum. At the meeting, Dr.
Stauber was also named an honorary
fellow of the the International College of
Cranio-mandibular Orthopedics.

Stauber

Rosenbluth named
Scholar-in-Residence

Sidney Rosenbluth,
Ph.D., dean of the
School of Pharmacy,
has been named a
Scholar-in-Residence
with the American
Association of
Colleges of
Pharmacy (AACP).

“For the next 10
months, I will work
and study at the
AACP’s headquarters
in Alexandria, Va.,” Dr. Rosenbluth said.
“I will study aspects of wellness from a
pharmacist’s point of view.”

Dr. Rosenbluth recently completed a
tenn as chair of the AACP’s Council of
Deans. He has resigned as dean, but
will return to the School of Pharmacy in
July 1955 for a full-time faculty post.
James Shumway, Ph.D., associate dean
for educational programs in the School
of Medicine, will serve as interim dean
while a search for a new dean is
underway.

Joseph Ma, Ph.D., has been named
interim assistant dean for research and
graduate programs in the School of
Pharmacy.

Dr. Ma, professor of pharmaceutics
and phannaceutical chemistry, joined
the School of Pharmacy in 1976. He
earned his doctoral degree in physical
chemistry from Duquesne University
and completed a postdoctural fellow-
ship in pharmaceutics at the University
of Georgia College of Phannacy.

Azzaro named to post
at Florida college

Albert J . Azzaro, Ph.D., professor of
pharmacology/toxicology, neurology
and behavioral medicine/psychology
in the School of Medicine, has been
named chair of pharmacology at the
Florida College of Osteopathic
Medicine in Tarpon Springs, Fla.

Dr. Azzaro has been a member of
the WVU faculty for 23 years. He was
director of the Chestnut Ridge Hospital
Clinical Pharmacology Laboratory for
Psychotropic Drug Analysis.

Fine needle aspiration
conference planned

On April 29, the West Virginia Bureau
of Public Health’s Breast and Cervical
Cancer Screening Program (BCCSP) is
sponsoring a CME conference entitled
“ Fine Needle Aspiration for Primary
Care with the WVU School of Medicine
Department of Pathology, the Office of
CME, the West Virginia Association for
Pathologists, and the West Virginia
Cytology Society.

This CME workshop will be held at
the Robert C. Byrd Health Sciences
Center in Morgantown, and is open to
pathologists, cytotechnologists, general
practitioners and nurses. Didactic and
hands-on sessions concerning clinical
topics and cytology will be presented.

For more details, contact Patricia
Hilton Wilbur at 293-2370.

440 THE WEST VIRGINIA MEDICAL JOURNAL

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finishes, 'The President Series mirrors the excellence of
the leaders it serves.

Subtle details make ‘ The President Senes the reference in
traditional design. Burl Walnut or hand-tooled leather-
inlay tops, optional leather-wrapped drawer pulls, and
hand-applied decorative molding enhance the beauty
of the series.

Interior Design Service
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Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

MU Med School ranks
2nd in U.S. in number
of grads entering FP

The Marshall University School of
Medicine ranked second in the nation
last year in the percentage of graduates
entering family practice residencies,
according to a study reported in the
September issue of Family Medicine.

The study, prepared by the American
Academy of Family Physicians, showed
that 32.7 percent of MU’s medical grads
entered family practice residencies in
1993- Only the Mercer University
School of Medicine ranked higher. MU
also retained its No. 3 ranking in the
three-year averages, with 27.7 percent
of graduates entering family practice
between 1991 and 1993- The study
included one- and three-year data from
every U.S. medical school, and one-year
data from osteopathic schools.

Dr. Robert B. Walker, chairman of
the Department of Family and
Community Health at Marshall, said
several factors contribute to the
school’s consistently good outcomes
in producing primary care physicians.

“We believe that our admissions
policies, our structure as a community-
oriented medical school, and strong
role models in primary care and rural
practice all play major roles,” he said.
“Certainly these results reflect
Marshall’s overall mission, which we
are gratified to see in our students’
choice of careers.”

Nationally, 12.3 percent of 1993
graduates entered FP residencies, the
highest percentage in a decade.

Students celebrate
Primary Care Day

Marshall medical students celebrated
the first National Primary Care Day
with a six-day series of lunchtime
programs from practitioners.

In addition to faculty members
representing each of Marshall’s

generalist departments, the series
featured Dr. Carroll Christiansen of
Summersville and Dr. Ron Stollings of
Madison. A follow-up event was
scheduled for early October to allow
first- and second-year medical
students to meet with Marshall
students who are participating in the
Rural Physician Associate Program,
the Kellogg Program, the Rural
Health Initiative and Marshall's
accelerated residency program in
family practice.

“We hoped to give first- and second-
year students a better understanding of
what a day in the life of a primary care
physician consists of,” said Brian
Brautigan, the president of the fourth-
year class who chaired the planning
task force. “We wanted to promote not
just primary care in general, but rural
primary care specifically. “We felt that
connecting students directly with
practicing physicians would help them
make more informed decisions about
the disciplines they want to go into,
and it also allowed them to become
familiar with the physicians at two rural
sites where they can do electives later,"
he added.

The concept of National Primary Care
Day originated from medical students
themselves. This first event was
sponsored by nine national groups of
med students and the Association of
American Medical College’s Office of
Generalist Physician Programs, and
students from at least 135 of the nation’s
142 med schools planned observances.

Biotechnology expert
consults with MU,
business leaders

Dr. Michael Pappas, scientist-author
of The BioBusiness Handbook , met
recently with MU and community
leaders to consider the potential for
developing biotechnology industry in
Huntington.

According to Dr. L. Howard Aulick,
assistant dean for research development
for the MU School of Medicine, a Center
for Applied Biotechnology would build
on campus-based expertise and help
establish successful private businesses
in the fields of forensic, medical and
environmental science.

marshaliMJniversity

“We have several groups of Marshall
researchers who are interested in
developing projects through a
biobusiness channel,” said Dr. Aulick.
“As we have talked to people in the
community, we also have found
individuals interested in the economic
development possibilities and even
potential investors. "We discussed our
business plans with Dr. Pappas so that
he can evaluate them and advise us on
the best way to proceed,” he added.

Dr. Pappas’ schedule included
meetings with the Huntington Area
Development Corporation (HADCO),
executives of the Marshall Research
and Economic Development Center,
and members of the Center for Applied
Biotechnology Team, which includes
representatives of Marshall’s College of
Business, School of Medicine, and
Center of Environmental, Geotechnical
and Applied Sciences.

MU plans to bring in several other
biotechnology experts in the coming
months. “We believe Huntington has
the potential to create a highly
successful biotechnology industrial
park,” Dr. Aulick said.

Dr. Pappas is director of analytical
chemistry and immunochemistry for
Advanced Instruments Inc. in
Norwood, Mass., and has operated a
biotechnology consulting company
since 1989. His credentials also
include two U.S. patents for diagnostic
procedures; proposal and manuscript
review services for many professional
organizations, and nine research
grants and contracts from federal,
state and private sources.

Medical alumni induct
Bateman, Collins

Marshall medical alumni recently
named Dr. Mildred Mitchell-Bateman
and Paul H. Collins honorary members
of their Alumni Association.

Dr. Bateman, an active faculty
member who was founding chair of
MU’s Department of Psychiatry, was
formerly director of the West Virginia
Department of Mental Health. Mr.

Collins played a key administrative role
in the school’s development, and served
as associate dean for administration
until he retirement in 1981.

442 THE WEST VIRGINIA MEDICAL JOURNAL

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Alliance

News

Working in Alliance with you and the WVSMA!

The name of the organization I represent is the West Virginia State Medical Association Alliance. The
WEST VIRGINIA STATE MEDICAL ASSOCIATION - - YOUR - - ALLIANCE. I believe we truly live up to that title
because we really strive to work in ALLIANCE with you and your organization!

We work in support of:

*your profession and its perception by the public;

*the legislative issues that affect your profession, medicine, as well as the health of the public;

*health issues that are of concern to you; and

*fund raising for medical education and research.

Is your spouse a member of West Virginia State Medical Association Alliance? Chances are, your answer
is NO because only 26% of the spouses of WVSMA members are members of the Alliance! If you truly believe
that the Alliance is supportive of the West Virginia State Medical Association, you should make sure your
spouse belongs to the Alliance this year.

I know, I know! Many of them are busy with their own interests. While we could certainly use their
willing “hands” to help with our work for you, we need their financial support (through their dues) even more!
I don’t have to tell you, money is very important to accomplish things in this world. So, I urge you to get your
spouses to pay their dues and join the Alliance. Or better yet, you pay their dues for them!

The project I have chosen for this year is “ Combating the Negative Effects of Media on Children and
Youth." Five actions of the 1994 AMA House of Delegates addressed components of this issue. It comes as no
surprise to anyone who has spent even a small amount of time around children that they imitate what they see
and hear. Think of the 18-month-old who hears an exasperated parent let loose an expletive - - more than
likely, that child will repeat that word! Multiply that by all the profane words children hear during their years of
exposure to TV, movies and radio, and it’s no wonder today’s young people use so much foul language!

Now, think of all the promiscuous sex that is modeled in our media. Each year the typical teen sees
14,000 sexual encounters JUST ON TV! Is it any wonder:

That 52% of females ages 15-19 and 75% of 18-year-old males admit to experiencing premarital sex;

That unmarried teen births had risen to 69% by 1991 despite the fact that abortions end 42% of all
pregnancies to women under age 20; and

That 1 in 8 teens in the U.S. acquires a sexually transmitted disease each year while the risk worldwide
is 1 in 20.

Now let’s look at violence. More than 3,000 studies by independent researchers consistently show that
repetitive viewing of violence:

*provokes imitative behavior in children;

^removes inhibitions on aggression;

*desensitizes children to violence so that they accept it as normal and natural; and

*can create exaggerated fears, especially in young children, about how dangerous the world really is.

The average child sees more that 40,000 murders and 200,000 rapes, stabbings, assaults, car wrecks and
screaming victims on TV alone by the time he turns 18. Is it any wonder teen violence is so rampant and carries
into adulthood? The yearly death toll due to handguns is 10 times higher than the death toll at the peak of the
polio epidemic in the 50s!

444 THE WEST VIRGINIA MEDICAL JOURNAL

WHO’S PROTECTING OUR CHILDREN? The future of today’s children is in our hands! What will we do

with it?

Your Alliance has printed a brochure addressing this issue as well as actions to take in combating the
problem. This brochure is available, free of charge, and appropriate for distribution to the public. If you would
be willing to make these available through your office or an organization you belong to, please contact a
member of your local Alliance or the WVSMA office to get a supply.

I look forward to serving on your Council and working in Alliance with you and your organization in
the coming year. Thank you for the support you give the WVSMAA.

Sue Bryant
WVSMAA President

MAKE A DIFFERENCE IN WV . . .

JOIN THE WVSMA ALLIANCE TODAY!!!

Help Us Confront The Problems Of:

^Media’s Negative Effects on Children

*Alcohol and Drug Abuse

*Domestic Violence

*Teen Pregnancy

*Teen Suicides

* Tobacco Use

*Violence

*Rape

Your $43 dues entitle you to both WVSMAA and AMAA memberships

Contact: Linda Elliott, WVSMA President Elect
6 Holly Road
Wheeling, WV 26003
242-5922

OCTOBER 1994, VOL, 90 445

Annual Audit 1993

The annual audit of the West Virginia State Medical
Association for the calendar year 1993 has been completed
by Ernst & Young of Charleston. The complete audited
financial statements including the report of independent
auditors is as follows:

REPORT OF INDEPENDENT AUDITORS

To the Council

West Virginia State Medical Association

We have audited the accompanying balance sheets of West Virginia State
Medical Association (the Association) as of December 31, 1993 and 1992,
and the related statements of revenues and expenses — unrestricted fund,
changes in fund balances, and cash flows — unrestricted fund for the
years then ended. These financial statements are the responsibility of the
Association’s management. Our responsibility is to express an opinion on
these financial statements based on our audits.

We conducted our audits in accordance with generally accepted auditing
standards. Those standards require that we plan and perform the audit to
obtain reasonable assurance about whether the financial statements are
free of material misstatement. An audit includes examining, on a test
basis, evidence supporting the amounts and disclosures in the financial
statements. An audit also includes assessing the accounting principles
used and significant estimates made by management, as well as
evaluating the overall financial statement presentation. We believe that
our audits provide a reasonable basis for our opinion.

In our opinion, the financial statements referred to above present fairly,
in all material respects, the financial position of West Virginia State
Medical Association at December 31, 1993 and 1992, and the results of its
operations and its cash flows for the years then ended in conformity with
generally accepted accounting principles.

Ernst & Young

March 30, 1994

BALANCE SHEETS— WVSMA

December 31

UNRESTRICTED FUND 1993 1992

ASSETS

Cash and cash equivalents — Note 4

$ 908,628

$ 721,859

Investments, at cost (market value $203,125

as of December 31, 1992) — Note 1

—

200,035

Accounts receivable

63,802

35,971

Other assets

14,734

16,719

Land, building, and equipment, net — Note 2

623,455

641,360

$1,610,619

$1,615,944

LIABILITIES

Dues collected in advance

$ 496,926

$ 552,758

Other deferred revenue

57,262

750

Medical scholarship obligation

9,163

13,663

Accounts payable

59,580

28,556

Accrued income taxes payable

8,000

7,706

Accrued expenses and other liabilities

15,353

32,486

Note payable to bank — Note 4

492,185

502,616

1,138,469

1,138,535

FUND BALANCE

Undesignated

472,150

477,409

$1,610,619

$1,615,944

Restricted Fund — Note 1

ASSET

Investment in common stock

$ 4,250

FUND BALANCE

Endowment

$ 4,250

STATEMENTS OF REVENUES AND EXPENSES— UNRESTRICTED
FUN D-WVS M A

Year Ended December 31

1993

1992

REVENUES

Dues

$ 738,458

$ 748,995

Professional liability services — Note 5

140,000

Contributions:

Legislative

—

8,495

Conferences and meetings

8,996

7,021

Interest and investment

39,693

41,002

Exhibit space income

48,600

51,200

Advertising

44,877

63,265

Registration fee income

53,248

42,705

Management fee income

—

5,000

Commission income

26,771

7,343

Other revenues

15,474

20,997

Total revenues

1,116,117

1,136,023

EXPENSES

Salaries and wages

282,377

289,790

Legislative

50,585

43,981

Interest expense

38,660

50,951

Publishing and printing

98,947

91,777

Convention speakers and supplies

90,201

94,904

Legal and accounting

89,007

76,889

Travel

72,874

85,659

Malpractice

38,884

29,132

Employee benefits

78,835

68,531

Depreciation and amortization

26,652

28.250

Postage

37,760

37,556

Payroll taxes

24,679

24,011

Office supplies

23,114

23,804

Telephone

17,806

15,824

President's stipend

9,500

5,000

Property taxes

13,129

11,395

Liability insurance

6,730

7,106

Medical students'/residents' subsidies

11,915

6,665

Computer repairs and maintenance

8,499

6,630

Utilities

6,236

6,792

Other expenses

88,538

90,479

Total expenses — net

1,114,928

1,095,126

Excess of revenues over expenses before taxes

1,189

40,897

Income tax provision:

Federal

5,040

—

State

2,944

—

7,984

—

( Deficiency) excess of revenues over expenses

$ (6,795)

$ 40,897

See notes to financial statements.

STATEMENTS OF CHANGES IN FUND BALANCES-WVSMA

Restricted

Unrestricted

Endowment

Fund

Balance at December 31. 1991

$434,992

$4,250

Excess of revenues over expenses

40,897

1,520

Transfer from endowment fund to

unrestricted fund

1,520

(1,520)

Balance at December 31. 1992

477,409

4,250

( Deficiency) excess of revenues over expenses

(6,795)

1,536

Transfer from endowment fund to

unrestricted fund

1,536

(1,536)

Balance at December 31, 1993

$472,150

$4,250

See notes to financial statements.

446 THE WEST VIRGINIA MEDICAL JOURNAL

STATEMENTS OF CASH FLOWS— UNRESTRICTED FUND — WVSMA

Year Ended December 31

1993

1992

OPERATING ACTIVITIES

(Deficiency) excess of revenues over expenses
Adjustments to reconcile (deficiency) excess of

$ (6,795)

$ 40,897

revenues over expenses to net cash (used in)
provided by operating activities:

Depreciation and amortization

26,652

28,250

Gain on sale of investments

(7,952)

(Increase) decrease in accounts receivable

(27,831)

13,107

Decrease (increase) in other assets
(Decrease) increase in dues collected in

1,985

(7,286)

advance

(55,832)

28,602

Increase (decrease) in income taxes payable

294

(4.832)

Decrease in medical scholarship obligations

(4,500)

—

Increase in accounts payable

Increase (decrease) in accrued expenses and

31,024

163

other liabilities

39,379

(5,819)

Transfer from Endowment Fund

1,536

1,520

Net cash (used in) provided by operating activities (2,040)

94,602

INVESTING ACTIVITIES

Proceeds from sale of investments

207,987

Purchases of equipment

(8,747)

(7,143)

Net cash provided by (used in) investing activities

199,240

(7,143)

FINANCING ACTIVITIES

Repayment of note payable to bank

(10,431)

(11,582)

Net cash used in financing activities

(10.431)

(11.582)

Net increase in cash

186,769

75,877

Cash and cash equivalents at beginning of year

721,859

645,982

Cash and cash equivalents at end of year

$908,628

$721,859

See notes to financial statements

NOTES TO FINANCIAL STATEMENTS— WVSMA

1. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES

Cash and Cash Equivalents: Cash and cash equivalents are comprised

of short-term certificates of deposit and money market accounts recorded

at cost, which approximates market.

Investments: In 1992, investments consisted of approximately 17,300
shares of a Federated GNMA Trust which are stated at the lower of cost
or market value. There were no sales of investments in 1992. In 1993, all
17,300 shares of Federated GNMA Trust were sold with a recognized gain
of $7,952.

Allowance for Doubtful Accounts: The Association values its accounts
receivable at net realizable value by expensing amounts determined to be
uncollectible in the period of determination.

Land, Building, and Equipment: Land, building, and equipment are
recorded at historical cost. Depreciation is computed by the straight-line
method using estimated useful lives ranging from 5 to 35 years. The cost
of maintenance and repairs is charged to income as incurred, and
significant improvements are capitalized.

Recognition of Revenue: Members are billed in advance for the
subsequent year's dues, which are treated as earned in the period to
which they relate. All dues received prior to January 1 are reported as
dues collected in advance.

Other Deferred Revenue: In 1993, the Association received $57,000 in
voluntary contributions from its members in support of pending litigation
involving newly passed legislative rules and regulations which affect the
practice of medicine in the State of West Virginia.

Medical Scholarship Obligation: Until 1987, the Association provided
scholarships to students attending the Schools of Medicine at West
Virginia and Marshall Universities for the purpose of defraying expenses
incurred by such students. A liability for the remaining scholarship
obligation is a part of the general fund.

Fund Balance: The Endowment Fund, a restricted fund, was established
to pay for the guest speaker at the annual meeting and consists of equity
securities stated at cost, which approximates market value.
Reclassifications: Certain amounts reported in 1992 have been
reclassified to conform with 1993 presentation. Such reclassifications had
no impact on excess of revenues over expenses as previously reported.

2. LAND, BUILDING, AND EQUIPMENT

A summary of land, building, and equipment, and the related allowance
for depreciation as of December 31, is as follows:

1993

1992

Land

$ 141,247

$141,247

Building and improvements

635,585

635.585

Furniture and equipment

228,273

219,526

1,005,105

996,358

Less allowance for depreciation

(381,650)

(354,998)

$ 623,455

$641,360

3. FUTURE MINIMUM RENTALS UNDER OPERATING LEASES

The Association leases office and computer equipment under
noncancellable operating leases with terms of one year or more. The
following is a schedule by years of minimum future rentals for the years
ending December 31:

1994 $19,200

1995 11,300

Total minimum future rentals $30,500

Total minimum future rentals do not include contingent rentals which
may be assessed under the office equipment lease on the basis of usage
in excess of stipulated minimums. Contingent rental expense in 1993 and
1992 approximated $7,000 for both years.

Rental expense in 1993 and 1992 approximated $32,000 and $27,000.
respectively.

4. DEBT

Terms of the agreement underlying the note payable to bank provide for
interest at 1% above the annual percentage yield of certificates of deposit
and other balances, if any, securing the loan. The note is repayable in
sixty monthly installments of $5,200 (including principal and interest)
followed by a balloon payment or re-amortization of the loan. The loan is
primarily secured by a first deed of trust on the building which has a net
book value approximating $451,000 at December 31, 1993. In addition,
the loan is collateralized by a $300,000 certificate of deposit and money
market account with a balance approximating $523,000 at December 31,
1993.

Interest paid approximated $39,000 and $51,000 in 1993 and 1992,
respectively.

Principal payments on the note payable in each of the next five years
ending December 31 are as follows:

1994

$ 39,649

1995

41,594

1996

43,636

1997

45,777

1998

321,529

$492,185

5. PROFESSIONAL LIABILITY SERVICES

The Association has separate agreements with Continental Insurance
Agency (CNA) and McDonough Caperton Insurance Group, L.P. (MCIG)
to provide educational and marketing services to the Association's
members relating to professional liability insurance. Under the terms of
the agreements, the Association is to receive up to $100,000 a year from
each company. The Association recognized income of $100,000 from
CNA and $40,000 from MCIG in 1993 and 1992.

6. RETIREMENT PLAN

The Association is a participant in a Prototype Corporate Defined
Contribution Retirement Plan (the Plan). All employees of the Association
are covered by the Plan as long as they are at least 21 years old and have
completed six months of service. The Association’s contribution
approximated $31,000 and $23,000 in 1993 and 1992, respectively, based
on 10% of the total compensation of all eligible participants. Employees
are vested in their participant account at the rate of 20% for each
completed year of service, up to 100% vesting after five years of service.

7. INCOME TAXES

Revenues of the Association are generally exempt from federal income
tax under Section 501(c)(6) of the Internal Revenue Code. However,
certain income, primarily advertising revenues and income received
under agreements with insurance providers for their educational and
marketing services and use of the Association’s membership lists, is
considered unrelated business income and is taxable to the extent it
exceeds allocable expenses.

The Association paid income taxes approximating $7,000 and $4,800 in
1993 and 1992, respectively.

OCTOBER 1994, VOL. 90 447

Obituary

James H. Nelson, M.D.

Dr. James Henry Nelson of Dunbar,
a longtime Charleston area physician
and the first black doctor admitted to
the Kanawha Medical Society, died
August 26 at General Division. CAMC.
after a long illness.

A native of Hinton. Dr. Nelson was
a graduate of West Virginia State
College and Meharry Medical College.
He did postgraduate studies at
Columbia University" and Temple
University and served his internship at

Agnes Hospital in Raleigh. N.C.

A former superintendent of Denmar
State Hospital and former assistant
medical director of Kanawha County
Schools. Dr. Nelson had a family
practice in Charleston and was a
charter staff member at CAMC and
Saint Francis Hospital. He was also a
former school physician at West
Virginia State College and a former
house physician at Harrell Nursing
Home and Washington Hotel. He had
retired from practice in 1985.

During his career. Dr. Nelson
received numerous awards, including

the Mr. Doc Award in 1981 and the
1993 Martin Luther King Award. He
was a 50-year member of the WVSMA
and was a member of many medical
and community organizations
including the Kanawha Medical
Society. National Medical Association,
the .American College of Chest
Physicians, the American Academy of
Family Physicians, the American
Academy of Family Practice, and the
West Virginia Medical. Dental and
Pharmaceutical Society".

Surviving are his daughter. Barbara
A. Carroll: and three grandchildren.

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448 THE WEST VIRGINIA MEDICAL TOURNAL

West Virginia Medical

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND

BALTIMORE

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EDITOR

Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Postmaster send form 3579 to the West
Virginia Medical Journal, 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL IOURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $36 a year in the U.S.;
$60 in foreign countries; $3 per single copy.
Address communications to the West
Virginia Medical Journal, P. O. Box 4106,
Charleston, WV 25364.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Road,
Ann Arbor, MI 48106.

USPS 676 740
ISSN 0043 - 3284

West Virginia Medical

OURNAL

Contents

Feature Articles

Access to medical care in West Virginia:

Implications for policy 458

Almost heaven? Rural family practice in West Virginia 462

Special Report

Questions and answers about WVSMA’s

newly endorsed medical malpractice insurer 464

Scientific Newsfront

Seventeen level laminectomy for extensive spinal epidural abscess:

Case report and review 468

An overview of adulthood attention deficit

hyperactivity disorder 472

A spontaneous esophageal perforation and duodenal ulcer

perforation resulting in a subpulmonic abscess 475

President’s Page

“I want you!" 478

Editorials

Access to medical care 479

The election 479

Our Readers Speak

A difference of opinion on endorsements 480

Special Departments

General News 482

Registration Form for WVSMA’s Mid-Winter Clinical Conference.... 485

Continuing Medical Education 486

Medical Meetings/Poetry Corner 487

Bureau of Public Health News 488

Robert C. Byrd Health Sciences Center of WVU News 490

Marshall University School of Medicine News 492

Med Student Section News 494

New Members/WESPAC Members 495

Obituary 496

Classified 497

November Advertisers 498

Front Cover

Autumn splendor at the Sinks of Gandy in Webster
County. Photo courtesy of Ron Snow, West Virginia
Department of Commerce.

NOVEMBER 1994, VOL. 90 457

Feature Article

Access to medical care in West Virginia:
Implications for policy

RENATE E. PORE, Ph.D., M.P.H,

University System of West Virginia, Charleston

DAN CHRISTY, M.P.A.

Information Project Specialist, University
System of West Virginia, Charleston

GARY THOMPSON, B.A.

Special Projects Coordinator, Health Statistics
Center, West Virginia Bureau of Public Health,
Charleston

Abstract

Access to medical care is an
important goal of health care reform.
In West Virginia, access to care has
been defined in terms of insurance
coverage and the availability of
health care professionals, especially
primary care practitioners. In
recent years, three surveys have
attempted to measure access to care.
These surveys show that
approximately 200,000 to 230,000
West Virginians needed medical care
but were not able to obtain it
because they could not afford it. A
much larger number, about 540,000
West Virginians, put off or postponed
seeking care they felt they needed
because they could not afford it.

Introduction

Since 1991, West Virginians have been
debating the issue of health care reform,
and these discussions have focused
mainly on the issues of cost and access.

This second factor, access, has been
defined by the West Virginia Health
Care Planning Commission as meaning
both financial access (adequate
insurance coverage) and the availability
of primary care practitioners in rural
areas of the state. Political leaders and
the general public, though, have very
different perceptions about access In
fact, some people state that there are
300,000 West Virginians who are
without insurance coverage and that
many more who have poor coverage
lack adequate access to medical care —
while others maintain that hospital
emergency rooms and private
practitioners provide for charity care

when it is really needed. Furthermore,
some individuals believe that West
Virginians who do not have insurance
coverage are generally young and
healthy and have no need of medical
care beyond routine preventive care.

Another serious barrier to the
availability of health care is the lack of
primary care providers. All or parts of
43 counties in the state, mainly rural
areas, have shortages of primary care
physicians which create special
hardships for the poor and the elderly
who do not have access to reliable
transportation. However, unpublished
data cited by Dr. John Pearson at the
West Virginia University School of
Medicine shows that Medicare
recipients in rural West Virginia have
just as many or perhaps more hospital
visits and procedures as their more
urban counterparts ( 1 ).

In the past two years, three surveys
have been conducted in West Virginia
which have shed light on this issue of
access to medical care and provided a
better understanding of the extent of
the problem. These surveys are:

• A Louis Harris Survey entitled West
Virginia Health Care Experiences,
which was conducted in West
Virginia in May 1992.

• The Behavioral Risk Factor
Surveillance Survey conducted by
the Health Statistics Center of the
West Virginia Bureau of Public
Health, Office of Epidemiology and
Health Promotion.

• The West Virginia Social Indicators
Survey conducted by the West
Virginia University Survey Research
Center.

This article describes the results of
each of these surveys as they relate to
access to medical care and will reflect
on some of the policy implications of
the survey results.

Louis Harris Survey

The Louis Harris Survey was a one-
time, cross-section telephone survey of
1,250 West Virginia adults which was
conducted in May 1992 to obtain

information about residents’ experiences,
fears, and concerns regarding health
care and health insurance. This survey
was similar to national surveys
sponsored by the Kaiser Family
Foundation and the Commonwealth
Fund. It was funded by the Claude
Worthington Benedum Foundation as
a collaborative effort between the
Health Care Planning Commission and
the West Virginia Hospital Research
and Education Foundation.

In the Harris survey, 13 percent of
West Virginia adults — the same
proportion as nationwide — said there
was a time in the previous 12 months
when they needed care but did not
obtain it. Most said that financial
reasons kept them from seeking care
(45% said it “cost too much” and 31%
said they were not covered by
insurance).

The Harris survey made a further
distinction between the individuals who
needed care and did not get it, and
those who were refused care. Ten
percent of West Virginia adults reported
that during the previous year they (3%),
someone else in their family (6%), or
both they as well as someone else in
their family (1%) had been refused
medical care because they did not
have insurance or could not pay.

In the 12 months prior to the
survey, 30 percent of the West Virginians
questioned said they put off or
postponed seeking care they felt they
needed because they could not afford
it. In addition, 12 percent of the
individuals in households with children
said they put off or postponed seeking
care for a child in the 12 months prior
to the survey.

Behavioral Risk Factor
Surveillance Survey

Since 1984, the Health Statistics
Center of the West Virginia Bureau of
Public Health has participated in the
Behavioral Risk Factor Surveillance
System (BRFSS), which was developed
and is funded by the Atlanta-based
Centers for Disease Control. This survey
provides data on health risk factors

458 THE WEST VIRGINIA MEDICAL JOURNAL

including smoking, seatbelt use,
alcohol consumption, hypertension,
obesity and sedentary lifestyle. Starting
I in 1991, questions were added to the
survey to address issues of health care
coverage, access and cost. During
1991 and 1992, a total of 4,817 adults
were asked if they had any type of
health coverage and if there was a
time in the past 12 months when they
needed to see a doctor but could not
because of cost.

The results showed that 16.1 percent
of West Virginians ages 18 and older
reported that they needed to see a
doctor but could not because of cost.
The survey did not distinguish
between those who were refused care
and those who did not seek care. The
BRFFS survey is of particular interest
and value because it is the only survey
which allows for the calculation of
rates by region. Figure 1 indicates
variations from as low as 12 percent
in the Northern Panhandle (District 6),
to a high of 18.6 percent in the
southwestern counties (District 2).

The BRFSS could be a valuable tool
for helping state policymakers target
resources to those areas with greatest
need. It may also be beneficial in
assisting policymakers to evaluate the
impact of system reform efforts, such
as the expansion of insurance coverage
and the development of rural health
networks.

WV Social Indicators Survey

The third survey measuring access
to care in the state is the West Virginia
Social Indicators Survey, which was
begun in 1992. Conducted by the West
Virginia University Survey Research
Center, this annual survey gathers data
on the social and economic conditions
of West Virginians. In 1993, questions
were added on insurance coverage,
satisfaction with health care services,
state government’s efforts in addressing
health care reform, and access to
medical care.

During the fall of 1993, 96 1 West
Virginia adults were surveyed. The
results indicated that 10.9 percent of
those responding had experienced a
time in the past 12 months when they,
or a member of their household needed
medical care and did not get it. The
survey did not ask for the reasons
why medical care was not received.

Of those adults who responded to
the survey, 81.5 percent had health
insurance coverage, and of that number,
6.5% reported that there was a time in
the past 12 months when they or a
member of their household needed
medical care but did not obtain it. In

the same survey, 18 percent stated they
had no insurance coverage, and of
these individuals, 30.5 percent reported
that they or a household member
needed medical care but did not
receive it (Figure 2).

Observations

While these three surveys suggest a
small variation in the severity of the
problem of access to medical care, all
surveys document that there is indeed
a problem. They indicate that even
West Virginians who have insurance
coverage may have a problem in
obtaining medical care when they
need it.

It is especially important to note the
results of the Harris survey which
show that almost one-third or 540,000
West Virginians reported that they put
off or postponed seeking care they felt
they needed because of cost. We
assume that people do not postpone
care in an extreme or life-threatening
situation; we also assume that not all

care that people think they need is
necessary or beneficial care. However,
we are also forced to conclude that a
substantial number of West Virginians
have put off necessary preventive or
primary care because they could not
afford it.

These surveys have important policy
implications regarding the issue of
cost-sharing and also the goal of
reducing the costs of health care. First
of all, some health reform proposals
suggest that increasing the financial
responsibility of individuals through
higher deductibles and co-payments,
will cause consumers to be more
prudent purchasers of care. The Harris
survey suggests that increasing the
financial burden on individuals will only
increase the number of those who
postpone seeking health care because
of cost.

Any policy that attempts to control
costs by discouraging West Virginians
from seeking primary care may only
confound another important policy

NOVEMBER 1994, VOL. 90 459

goal of improving the overall health
status of West Virginians. Preventive
care and proper outpatient management
of chronic diseases can prevent hospital
admissions and more costly treatments.

A recent Robert Wood Johnson
Foundation report states that “adequate
and timely ambulatory' care may prevent
hospitalizations for such chronic
conditions as asthma, congestive heart
failure, and diabetes. Effective outpatient
treatment of acute conditions - like
pneumonia and cellulitis - may prevent
complications requiring hospitalization.
Such preventable hospitalizations are
known as ambulatory sensitive (ACS)

admissions.” The report also states
“that adults living in low-income
neighborhoods are about three times as
likely to be hospitalized for ACS
conditions as people from high-income
neighborhoods” (2).

This report and the three surveys
suggest that policies to control health
care costs should promote easy access
to ambulatory care. Even though health
services research is in its infancy and
survey data requires cautious
interpretation, it seems obvious that
investing dollars in preventive and
primary care now may save us
millions later.

As West Virginians develop health
reform policies, policymakers should
avail themselves of the best research
available and thoughtfully consider the
implications of contradictory policy
initiatives.

References

1. West Virginia Medical Institute. Unpublished
Medicare data, 1992.

2. Center for Health Economics Research, The
Robert Wood Johnson Foundation. Access
to health care, key indicators for policy.
Princeton, NJ: November 1993:66.

(Please see the editorial on page
479 relating to this article).

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Feature Article

Almost heaven?: Rural family practice in

West Virginia

GREGORY JUCKETT, M.D.

Assistant Professor of Family Medicine, Robert
C. Byrd Health Sciences Center of West
Virginia University , Morgantown

It is commonly agreed that the
United States is experiencing a rural
health crisis, which is especially
severe in West Virginia because of the
large number of people living in
poverty and the inaccessibility of much
of our terrain. Most small towns are
unable to afford primary care physicians,
and those that do usually lose them in
relatively few years.

As a result of the shortage of rural
physicians, many people living in rural
areas must drive long distances to
hospital emergency rooms or use
expensive “city” specialists for care.
Medicaid patients, in particular, have
had little choice besides utilizing
emergency rooms since participating
providers are few and far between.
Those seeking obstetrical care may have
even farther to travel since many rural
hospitals no longer offer delivery
services.

What has gone awry with rural
health care? Some answers are
obvious — too few generalists,
inadequate reimbursement, poor
school systems, professional isolation,
and physician burnout. Most of the last
generation of old-time family doctors
are either deceased or retired, and their
ranks, for the most part, have never
been replenished. There has been much
talk about how to correct this sad
situation, but until recently very few
measures had been taken to actually
improve the number of rural physicians.
The increased talk of health care
reform, though, has made primary
care once again fashionable and the
economic base for rural physicians
somewhere brighter because of the
possibility of universal coverage
within the next several years.

Until recently, I was a rural family
doctor. 1 still miss my patients and the
rambling discussions about gardens,
beehives, that eight-point buck that got

away, and the many other topics
pertaining to rural life. There was an
illusion of indispensability and a
definite certainty of purpose that
made each day worthwhile. Rural life
is a curious mixture of joy and sorrow —
joy at human bravery in the face of
illness and hard work, and sorrow
over the inevitable defeats that occur.
Many patients, lacking education and
insight, were trapped in a cycle of
hopelessness from which they seemed
powerless to extricate themselves.

A good example of this cycle of
hopelessness is what could be termed
“Appalachian wife syndrome.” This is
the situation where a young girl drops
out of school and hastily marries due
to an unplanned pregnancy, only to
find herself stranded in a trailer at the
end of a dirt road. After a few years,
she becomes depressed because she is
living in poverty with only young
children for company.

Changing this situation poses real
problems — an absentee husband
reluctant to enter (or afford) marriage
counseling, no daycare facilities, no
independent transportation, no
driver’s license or high school
diploma, no job skills, and no phone.
As a result of all of these difficulties,
women in these types of situations
lacked self confidence and believed
that change was not possible. I found
myself prescribing Prozac for these
patients instead of trying to intervene
in all aspects of their lives, thankful
that Medicaid would paid the bill for
such an expensive prescription.

Even though many of these women
said they felt hopeless when I first
started seeing them as patients, there
were some remarkable successes,
attributable mainly to individual
courage in the face of adversity, not
the effect of any medication. Of
course, a script for birth control pills at
just the right time could go a long way
toward preventing an otherwise
recurring problem. On these days, my
job was incredibly satisfying in spite
of the hardships.

Having made a list of the pros and

cons of rural family practice, I must
confess that the con list is longer — at
least at this time. The pros, however,
have incalculable worth!

First of all, I was impressed by the
decency and the kindness of my
patients, who, for the most part,
would give you the shirt off their back
if they thought you needed it. There
were a few exceptions, but they made
up for it by being “interesting.” The
self-styled curmudgeons were my
favorites.

In addition to the people, there are
many other wonderful benefits to
practicing in a small, rural town. There
is a sense of timelessness and beauty
about the land which can, in spite of
its isolation, still move one to tears
each spring. Can one put a price on
encountering a Hock of wild turkeys on
the way to work, having lunch on a
bank of wild trillium, or on hearing
wild birds sing on the way home?
There is also a sense of place and
community that is enriching to the
spirit in small rural towns. You feel
centered after a time, and fondly
imagine growing old in the town like
the one I practiced in and developing
deeper friendships as the seasons pass.

There is a price to pay, of course, for
all of these amenities. Up front, you
make less money — lots less money.
Many rural clinics are unable to pay
much and hence attract only young
doctors with heavy medical school
debt (with promises of forgiveness)
and foreign-trained physicians required
to work in health manpower shortage
areas. Mixed in with these physicians
are a few locally-raised docs returning
with real commitments to their
community, and a few idealists with a
Peace Corps mindset. Many move on
after a few years because of
professional isolation, dissatisfaction
with income, boredom, or burnout.

There is also an unstated, but very
real problem with personal privacy for
any rural physician. It is often assumed
that you will be willing, even eager, to
discuss the most trivial medical
problems. Many times you may be, but
when every trip to the local grocery

462 THE WEST VIRGINIA MEDICAL JOURNAL

store results in multiple consults, it
inexorably wears one down. At times it
is undoubtedly quicker to drive out of
town to shop than to “run the gauntlet”
at the local checkout counter.

Rural physicians in practice for
themselves may find it especially
difficult to have enough time for their
families because of the demands of
their patients. Since there are limited
coverage options, many rural patients
would often rather “drop by” their
doctor’s home in town than see an
assigned doctor in the next town.
Vacation coverage is extremely
difficult, if not impossible, to obtain,
usually costing far more than the
practice can bear. It is often less
stressful not to take a vacation!

Other factors to consider about
practicing in a rural environment are
the substantial Medicaid burden, high
malpractice rates, and the mountains
of mind-numbing paperwork — the
completion of which squanders
countless precious hours. Bill
collection too can be a real problem
at times, especially when people have
little or no third party coverage. When
the coal miners and their families lose
their insurance in the inevitable,
protracted strike, the financial picture
really gets grim. In addition, as rural
hospitals in West Virginia fold one by
one, many of the physicians
associated with them are having to
leave the local communities as well.

It is frustrating to note that physicians,
health care administrators and
hospitals are often their own worst
enemies. Rural hospitals and their
allied medical personnel repeatedly
vie for each other’s turf in a bizarre
“dance macabre” that can terminate
only with their mutual demise. It is as
if we inhabit a shrinking pond and
must rend each other in our attempts
at survival rather than look to see who
is siphoning off the water. A spirit of
cooperation rather than competition is
urgently needed. Unfortunately, some
hospital administrators may have a
natural tendency to place their job
security and power over the interests
of physicians and patients. A well-
entrenched health care bureaucracy
can, therefore, even with the best of
intentions, fail to maximize health care
in its region.

Last but not least, is perhaps one of
the most overlooked reasons for a
physician to depart a rural area — an
unhappy spouse. Just because the
physician is content with a rural
lifestyle doesn’t mean that his/her
spouse (usually met at an urban college
or medical school) will be just as

happy. There may be a dearth of
friendships with those of similar
educational backgrounds and interests.
Poor, run-down, understaffed schools
though, are one of the chief reasons
why doctors and their spouses abandon
rural practice, and I personally know
of several colleagues who have left the
state for this very reason — concern for
their children’s education. In short, no
placement will work unless the spouse
is happy with the community, available
education, social environment and
their partner’s work schedule.

With all of these problems, why am
I optimistic about the future of rural
health care in West Virginia? First of
all, times are changing. As painful as
national health care reform may seem,
if it does become a reality within the
next few years, it may help improve our
state’s shortage of rural physicians
because the status of primary care
providers would improve, making it
more feasible to practice in a rural
area. Of course, like most physicians,

I am fearful of the loss of physician
and patient autonomy, the inevitability
of rationing in some form, and the
prospect of increased taxes, all of
which seem likely, if unstated,
consequences of most of the plans
proposed in Congress last session.

I first became convinced that there
was a need for health care reform when
a woman hemorrhaging from advanced
cervical carcinoma came to my office
in tears. There had just never been
enough money in the family budget to
cover the cost of groceries, let alone
obtain pap smears. Her family had no
health insurance and was already
overburdened with medical debt for
the children’s care. Within a year, her
children had no mother.

Unfortunately, this was not an
isolated case. Several of my other
patients died as a result of delaying
care because they couldn’t afford it,
while others ended up suffering
immense pain for long periods of time
for this very same reason. It was also
very frustrating and depressing for me
to have to negotiate with elderly
patients who had to make the terrible
choice of either filling their costly
prescriptions or eating properly
because of their limited incomes. In
addition, many of my younger
patients held part-time jobs which did
not offer health care benefits, and
their incomes were not enough to
purchase coverage. If they or a member
of their families suffered from a chronic
illness, it was actually financially and
medically more advantageous to go on
welfare than to continue to work!

If health care reform is to be
worthwhile, it must address the
problems I have mentioned. First and
foremost, a network of rural health
centers must be set up to reach specific
underserved areas. Each community
must have a major stake in its clinic
and be heavily involved in providing
its own health care to be effective.
Since isolated physicians would still
need assistance to prevent burnout,
outreach from the nearest medical
school (not control) could provide
vital support with rotating faculty,
residents and students. The universities
could also provide continuing
intellectual stimulation through evening
CME programs and by offering visiting
clinician programs. Both the clinics and
the universities would benefit from this
type of arrangement, which basically
exchanges service for education.

Other measures, such as improving
the school systems in the rural
communities, trimming the bureaucracy
and paperwork, ensuring reasonable
incomes, passing tort reform to create
a more favorable practice climate, and
providing incentives for medical
students to return to their communities
after completing residencies, must be
taken if rural practice is to become
more attractive to medical students and
residents. Some of these interventions
have already been proposed, and a
few have been implemented.

I feel that unless real reform takes
place in the United States and West
Virginia, it is futile, perhaps even
immoral, to lure young physicians into
what may be an untenable practice
situations. While subsidies for mral
clinics will undoubtedly be necessary
for many years, I have fears that such
support could abruptly dry up in a
future budget crisis with disastrous
results. What will happen to these
clinics when rural health becomes less
of a “hot” issue? A well-planned
weaning period will be necessary if
these fledgling clinics are to be
successfully guided into maturity.

I have, for the most part, very happy
memories of my years in rural practice.
Like most aspects of life, you take the
good with the bad and, with time, the
better times overshadow the other. I
do not regret practicing rural medicine
for one minute, and I still have twinges
of guilt at having left my small-town
practice. Even though my present job
has many advantages for my family and
me, I find myself excited when
discussing rural health with students
and hoping that some of them will, in
turn, be able to help transform the
system in the near future.

NOVEMBER 1994, VOL. 90 463

Special Report

Questions and answers about WVSMA’s
newly endorsed medical malpractice insurer

Editor’s Note: Reaction has been overwhelmingly positive
to the West Virginia State Medical Association’s
endorsement of Medical Assurance of West Virginia, Inc.
as the professional liability insurer of choice. Physicians,
though, have asked many questions about Medical
Assurance and we are sharing some of them with you in
order to increase understanding about this company and
the coverage options they offer members of the WVSMA.

If you have additional questions concerning this subject,
please contact WVSMA Executive Director George Rider at
(304) 925-0342.

Q: I’m happy that we have a strong, stable carrier

committed to insuring West Virginia physicians, but
will we have to pay for this stability through higher
premiums?

A: No. Medical Assurance’s premiums are lower than

those of the carrier the WVSMA endorsed prior to
Medical Assurance.

Q: Is Medical Assurance of West Virginia rated by A. M.

Best?

A: Medical Assurance is rated A+ (Superior) by Best.

This is a good yardstick by which to measure other
carriers in West Virginia.

Q: Does Medical Assurance require me to make any

contributions before I can become insured?

A: No. Medical Assurance’s financial condition is so

strong they don’t have to require a surplus
contribution.

Q: If I have a claim that I think should be defended,

can Medical Assurance settle without my consent?

A: No! Medical Assurance is dedicated to the strongest

possible defense, and their policy requires that the
physician must consent to settle any claim. That’s
something that some carriers in West Virginia don’t
offer.

Q: I understand that West Virginia physicians will have

a significant role in the insurance decisions made
by Medical Assurance. How will this work?

A: Medical Assurance is a subsidiary of Mutual

Assurance, Inc., one of the leading physician-
founded malpractice insurers in the nation. Because
of the company’s background, Medical Assurance
welcomes physician participation through
organized Claims and Underwriting Committees.
These committees will be your voice to the
company.

Q: Is Medical Assurance going to insure everyone who

is now in the WVSMA’s sponsored program?

A: Yes! Medical Assurance has guaranteed first year

acceptance for physicians who currently participate
in the WVSMA program. After the first year of the
program, Medical Assurance may underwrite
physicians according to their standard procedures.
Physicians switching from other carriers will be
subject to underwriting review before initial
acceptance.

Q: Will Medical Assurance provide claims-made and

occutrence policies?

A: Medical Assurance will offer only claims-made

policies. However, they have made special
arrangements for physicians with occurrence policies
to enter the Medical Assurance claims-made program.

Q: I have a claims-made policy. What about my

retroactive date? Do I have to buy “tail coverage?”

A: Medical Assurance will accept the retroactive dates

for all physicians who are currently insured in the
WVSMA program. Physicians who are switching from
another carrier to Medical Assurance should consult
their agent, but should consider buying tail coverage.

Q: What type of discounts are available from Medical

Assurance?

A: Medical Assurance offers a wide range of premium

discounts, such as 10% for membership in the
WVSMA. Physicians entering practice within two years
of completing a recognized residency program will
receive a discount of 65% in the first year of
coverage, 35% in the second year. A five percent loss
prevention discount will be applied at renewal
following attendance at a Medical Assurance Risk
Management Seminar; this discount will be good for
two years. Initially, Medical Assurance will honor
seminar attendance from the previously endorsed
carrier.

Q: Will Medical Assurance offer the same limits I have

now?

A: Medical Assurance will offer limits of $1 million per

occurrence/$3 million yearly aggregate, but given the
nature of the medical/legal system in our state, you
are encouraged to consider the additional limits
available — up to $1 1 million in $1 million increments.

Q: How do I make the switch to Medical Assurance?

A: Simply contact WVSMA Executive Director George

Rider at (304) 925-0342 for details.

464 THE WEST VIRGINIA MEDICAL JOURNAL

SUCCESSFUL

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• 1993 Tax Law Overview

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• Estate Planning

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Registration Fee $250.00
Spouse Fee $125.00

Spouse’s fee waived if registered 10 days before start of seminar.

If you would like to have a special seminar done in your area , notify
the Medical Association. We will be happy to accommodate you.

Seminars Consist of Three Sessions
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Lite Meal Sened

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Remember, spousal fee is waived if reservations are confirmed 10 days prior to the seminar date
Return this self-addressed card, or call the WVSMA at (304) 925-0342.

Please Call Today!!!

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If you want to
know about

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Medical Assurance of West Virginia stands behind
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Rated A+ (Superior) by A. M. Best, and endorsed
by the West Virginia State Medical Association,
Medical Assurance is the secure, affordable
choice for your medical malpractice insurance.

.Medical

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To learn more about our commitment to West Virginia physicians, call:
Medical Assurance Acordia ofWest Virginia WVSMA

(304) 346-8228 (304) 346-06 1 I (304) 925-0342

Seventeen level laminectomy for extensive
spinal epidural abscess: Case report and review

BRYAN K. RICHMOND, M.D.

Department of Surgery, West Virginia
Un ivers ity/Cha rleston Division
JOHN H. SCHMIDT III, M.D., F.A.C.S.

Department of Neurosciences, West Virginia
University/Charleston Division

Abstract

Several studies have suggested that
non-operative treatment be employed
for spinal epidural abscesses
involving a considerable length of
the vertebral column. The reasons
for this have not been clearly stated
in the literature, however, nor has
the critical number of vertebral levels
been specified. Presumably, this is
related to the morbidity of extensive
laminectomy, but we began to question
this assumption because of advances
in surgical instrumentation combined
with frequent reports of irreversible
disease progression while on
appropriate antibiotics. In this article,
we present a case of an extensive
spinal epidural abscess managed
surgically with no associated
morbidity. In addition, we present a
review of the literature concerning
spinal epidural abscess.

Introduction

Spinal epidural abscess is a
frequently misdiagnosed and potentially
devastating condition, often constituting
a neurosurgical emergency. Recent
studies indicate that the incidence is
increasing (1,2,3); and surgical treatment
consisting of laminectomy and drainage
of the abscess coupled with appropriate
antibiotic therapy remains the mainstay
of treatment (4,5).

Medical management has been
recommended if the infection spans a
considerable length of the vertebral
canal (6), but the reasons for this are
not made clear in the literature. Reports
of disease progression while on
antibiotics combined with the
irreversible nature of the neurological
deficit (1,5) makes medical
management risky.

The abrupt onset of cardiorespiratory
arrest from sepsis and neurological
deficit in our patient while on
appropriate antibiotics necessitated
extensive laminectomy for drainage of
an extensive spinal epidural abscess.
This was accomplished with no
additional morbidity to the patient.

Case report

A 27-year-old diabetic female was
admitted to the Charleston Area Medical
Center from a small rural hospital after
a two-day history of nausea, vomiting,
malaise, fever, dizziness and
weakness. She also complained of
pain in her lower back and buttocks
on which was noted several draining
skin abscesses secondary to chronic
hidradenitis suppurativa.

Neurologic examination was
unremarkable on admission. Blood
cultures were obtained which grew
methicillin-sensitive S. Aureus.

Appropriate parenteral antibiotic
therapy was then initiated.

Over the next two days, the patient
remained febrile and developed nuchal
rigidity and an altered mental status.
Lumbar puncture was perfonned which
revealed purulent CSF, and she was
transferred to a tertiary care center
with the diagnosis of meningitis.

Immediately after arrival at the
tertiary care center, this patient
suffered a cardiorespiratory arrest.
Following resuscitation, she was
unable to move her lower extremities.
In view of the acute onset of
paraplegia combined with the clinical
picture, the diagnosis of spinal
epidural abscess was considered.
Frank pus was aspirated from the
lumbar epidural space, confirming the
diagnosis. Total cord myelography
was performed by Cl -2 puncture
which showed narrowing from the
mid-cervical spine to the sacrum, but
no block. This was followed by CT

Figure 1A. Post myelogram CT of cervical vertebrae showing large extradural defect.

468 THE WEST VIRGINIA MEDICAL JOURNAL

scan which revealed an extradural
defect involving the same distribution
(Figures 1A and IB).

In view of her rapid deterioration
and sepsis combined with the acute
onset of paraplegia, laminectomy
surgery was performed on this patient
which revealed a large epidural abscess.
Drainage and debridement of the
abscess necessitated the removal of
the laminae from the SI to T2
vertebral levels. This procedure was
accomplished in slightly over two
hours using the Midas Rex instrument
with the SI bit (Figures 2A and 2B) as
a laminar saw. No dural lacerations
occurred and suction drains were
placed in the epidural space prior to
w'ound closure. Estimated blood loss
was 500 ml. Figure 3 shows the
radiograph taken postoperatively
which demonstrates the extensive
laminectomy defect.

Following the surgery, this patient
was continued on parenteral antibiotics.
She was eventually discharged home,
but remained paraplegic until her death
two years later, which was caused by an
illness unrelated to her epidural abscess.

Discussion

Spinal epidural abscess remains a
rare phenomenon. Since it was first
described by Morgagni in 1769 (7), a
few hundred cases have been reported
in the literature. About one case per
year is diagnosed in the average
referral hospital (5), and studies have
reported relatively stable incidences of
spinal epidural abscess ranging from
0.2 to 1.2 patients per 10,000 hospital
admissions (4,8). Recent studies,
however, have suggested that the
incidence is increasing.

Hlavin et al reported an incidence
of 2.8 cases per 10,000 admissions
over a 10-year period (1). Nussbaum

et al also reported a steady increase in
the incidence of spinal epidural
abscess over a 10-year period, and in
fact noted 11.31 cases per 10,000
admissions during the last nine months
of their study. The authors concluded
that this was likely due to an increase
in the usage of illicit intravenous
drugs, which was documented in 40

percent of their patient population
(2,3). Other possible explanations
include the growing number of spinal
procedures such as surgical
decompression and stabilization, spinal
anesthesia, and local injections for
pain relief (1,9,10,11,12).

Predisposing factors to the
formation of epidural abscesses are

Figure 2A. Photograph of Midas Rex instrument with S-l bit. Figure 2B. Model illustrating use of Midas Rex with S-l bit as a

laminar saw for rapid laminectomy.

NOVEMBER 1994, VOL. 90 469

intraveneous drug abuse, diabetes
mellitus, blunt spinal trauma, cirrhosis,
alcoholism, chronic renal failure,
chronic steroid usage, para or
quadriplegia, and infection with the
human immunodeficiency virus
(1,3,4,5,11,13,14,15,16). Of these
factors, diabetes and intraveneous
drug abuse have demonstrated the
greatest clinical significance in several
studies (1,3,5,11,13,14,15,17,18).

The majority of patients are infected
via hematogenous dissemination from
a remote site of infection (1,19,20). A
history of concurrent infection is
found in 75%-85% of the cases (8).
Skin and soft tissue infections remain
the leading source and were the cause
in this patient.

Paraspinal infections after spinal
procedures have also been reported,
not only after open operations but
also after closed procedures such as
epidural anesthesia, local injections
for pain relief, and lumbar puncture
(1,10,12). Infected vascular access,
urinary tract infection and dental
abscesses represent less frequent
sources (5,1). In addition, contiguous
spread of infection to the epidural
space has been reported from
vertebral osteomyelitis, as well as
decubitus ulcers and psoas or
paraspinal abscesses (4,5,16,17).

Gram negative organisms are found
in less than 15 percent of cases,
although the incidence appears to be
increasing. Gram negative infections
were initially reported to be in higher
association with intravenous drug
abuse, but this has not been
confirmed in the most recent studies
(1,18). Fungal epidural abscesses have
also been reported, although much
less frequently (11).

The clinical presentation is highly
variable, which results in initial
misdiagnosis in up to 50 percent of
the cases (9). This, in turn, results in
long delays between presentation and
appropriate treatment. The course of
spinal epidural abscess is described as
having these four stages:

( 1 ) Spinal ache

(2) Root pain

(3) Weakness

(4) Paralysis

Headache and nuchal rigidity may
also be present (8,17). In addition, the
majority of patients present with non-
specific complaints such as fever and
malaise (1,3,4,5,20). Weakness or
paralysis may not develop for several
months, or may occur suddenly (21),
as was the case with our patient.

The mechanism of the often abrupt
onset of neurological deficit remains

poorly understood. Autopsy evidence
has indicated that mechanical cord
compression by the abscess is not an
adequate explanation, since not all
postmortem specimens have showed
evidence of cord compression in
proportion to the clinical picture (22).

Others support the concept of a
vascular mechanism. Russel et al
observed venous compression with
preservation of the arterial supply,
thrombosis and thromophlebitis of the
epidural space and cord, and venous
infarction and edema of the cord (23).
Hlavin et al proposed that this theory
could explain the rapidity of onset,
the irreversibility, and their observation
of a “central cord” pattern in one of
their patients (1).

Early diagnosis of epidural abscess
is crucial for a good outcome. The
presence of fever with spinal pain and
tenderness should suggest the diagnosis,
particularly if a predisposing factor or
source of infection is present (20).
Gadolinium magnetic resonance
imaging is the preferred radiologic
examination, allowing direct
visualization of the intervertebral disks,
spinal cord, and soft tissues including
the abscess itself. Myelography
followed by CT scan is an alternative
and should be used if bacterial
meningitis is suspected, since MRI
poorly distinguishes the subarachnoid
space for the surrounding epidural
tissues (18,24). Since bacterial
meningitis was suspected in this patient,
CT-myelography was chosen over MRI
as the most appropriate study. Plain
radiographs are largely unyielding and
are not useful as a screening
procedure (1,17,20).

Recent studies continue to support
immediate decompressive
laminectomy accompanied by
appropriate parenteral antibiotic
therapy as the treatment' of choice for
localized abscesses (1,3,5,15, 17,20).
Garrido and Rossenwater have reported
success with the suction-irrigation
technique as an adjunct to surgery (25),
but the majority of recent series report
no experience with this.

Several small studies have reported
success with non-operative
management (6,13), but the authors
acknowledge that their patient
populations had less severe
neurological impairment at the time
treatment was instituted with
antibiotics. However, Hlavin and
colleagues noted that 9 of 39 patients
in their series progressed to greater
neurologic deficit while on appropriate
antibiotics (1), as was the case with
our patient.

Figure 3. Plan radiograph taken after
surgery which shows the extensive
laminectomy defect.

Leys and colleagues stated that any
patient who experiences rapid
neurological deterioration should
undergo surgery immediately (6), but
they recommend that the following
patients with epidural abscesses receive
medical management exclusively:

(1) Those who are poor surgical
candidates because of severe
concomitant medical problems,

(2) Those who have abscesses that
involve a considerable length of
the vertebral canal,

(3) Those not suffering severe loss of
spinal cord or cauda equina
function; and

(4) Those who have remained
completely paralyzed for more
than three days.

The surgical procedure consists of
decompressive laminectomy with
drainage and debridement of the
involved area. As stated previously,
Leys and colleagues recommend that
surgery should not be performed for
abscesses involving a considerable
length of the vertebral canal, unless
the patient experiences rapid
neurological deterioration (6). We feel
that this approach is problematic in
view of the irreversible nature of the
neurologic deficit, as well as the
documented tendency of the
condition to progress while on
appropriate antibiotic therapy.

In addition, the literature has not
elaborated on the reasons for avoiding
surgery in this situation, or the critical
number of vertebrae involved that
should preclude operative management.

Several studies have reported
patients with large epidural abscesses

470 THE WEST VIRGINIA MEDICAL JOURNAL

involving much of the vertebral
column, but it is if these patients
underwent surgery and what was the
outcome, since only cumulative
statistics were provided (4,5,3). We
suspect that non-operative therapy
was recommended to avoid the
morbidity of such an extensive
laminectomy. However, by using
modern pneumatic instrumentation
(Midas Rex instrument with S-l bit),
we were able to accomplish a
laminectomy from SI to D2 in
approximately two hours, with a total
blood loss of 500 ml. Our hospital
course was free of morbidity related
to the operation; and at the time of
her death two years after discharge,
she exhibited no evidence of spinal
instability.

Instability after extensive laminectomy
has been a concern, but this does not
seem to occur commonly (15).
Exceptions include children in which
an extensive laminectomy is not
recommended (25), and in cases of
vertebral osteomyelitis with vertebral
body destruction, in which case
stabilization may be required (15).

Conclusion

The prognosis of spinal epidural
abscess best correlates with the
degree of neurological deficit at
presentation and the delay in correct
diagnosis and treatment (14). Mortality
in several recent studies has ranged
from 5%-23% percent, which shows
considerable improvement over earlier
studies. This is felt to be due to
continued improvement of antibiotic
agents and heightened awareness
leading to earlier recognition (17).

We feel that the unpredictable and
often devastating course of this illness
combined with improved surgical
instrumentation necessitates further
investigation into the role of early
surgical intervention in treating
extensive spinal epidural abscesses.

Disclosure

The authors wish to state that they
have no financial interest in any
product mentioned in this article.

References

1. Hlavin ML, Kaminski HJ, Ross JS, et al.

Spinal epidural abscess: A ten-year
perspective. Neurosurgery 1990;27:177-84.

2. Koppel BS, Tuchman AJ, Mangiardi JR, et
al. Epidural spinal infection in intravenous
drug abusers. Arch Neurol 1988;45:1331-7.

3. Nussbaum ES, Rigamenti D, Standiford H, et
al. Spinal epidural abscess: a report of 40
cases and review. Surg Neurol 1992;38:225-31.

4. Baker AS, Ojemann RG, Swartz MN, et al.
Spinal epidural abscess. N Eng J Med 1975;
293:463-8.

5. Darouiche RD, Hamill RJ, Greenberg SB, et al.
Bacterial spinal epidural abscess: Review of 43
cases and literature survey. Medicine 1992;
71:369-85.

6. Leys D, Lesoin F, Viaud C, et al. Decreased
morbidity from acute bacterial spinal epidural
abscess using computed tomography and
nonsurgical treatment in selected patients.

Ann Neurol 1985;17:350-5.

7. Morgagni GB. De sedibus et causus morborum
per anatomen indagatis. In: Alexander B,
editor. The seats and causes of diseases
investigated by anatomy. Letter X, Article 13-
New York: Hafner, 1960:220-2.

8. Heusner AP. Nontuberculous spinal
epidural infections. N EngJ Med 1948;
239:845-54.

9. Danner RL, Hartman BJ. Update of spinal
epidural abscess: 35 cases and review of
the literature. Rev Infect Dis 1987;9:265-74.

10. Ferguson JF, Kirsch WM. Epidural empyema
following thoracic extradural block. J
Neurosurgery 1974;41:762-4.

11. Kaufman DM, Kaplan JG, Litman N.
Infectious agents in spinal epidural
abscesses. Neurology 1980;30:844-50.

12. North JB, Brophy BP. Epidural abscess: a
hazard of spinal epidural anesthesia. Aust
NZ J Surg 1988;49:484-5.

13- Mampalam TJ, Rosegay H, Andrews BT, et
al. Nonoperative treatment of spinal
epidural infections. J Neurosurg 1989;
71:208-10.

14. McGee-Collett M, Johnston IH. Spinal
epidural abscess: presentation and
treatment. A report of 21 cases. Med J Aust
1991;155:14-17.

15. Rea GL, McGregor JM, Miller CA, et al.
Surgical treatment of the spontaneous
spinal epidural abscess. Surg Neurol 1992;
37:274-9.

16. Verner EF, Musher DM. Spinal epidural
abscess. Med Clin N Am 1985;69:375-84.

17. Del Curling O Jr., Gower DJ, McWhorter
JM. Changing concepts in spinal epidural
abscess: A report of 29 cases. Neurosurgery
1990;27:185-92.

18. Smith AS, Blaser SI. Infections and
inflammatory processes of the spine. Rad
Clin N Am 1991;29:809-27.

19. Bouchez B, Amott G, Delfosse JM. Acute
spinal epidural abscess. J Neurol 1985;
321:343-4.

20. Yang SY. Spinal epidural abscess. NZ Med J
1982;9S:302-4.

21. Currier BL, Eismonth FJ. Infections of the
spine. In: Rothman RH, Simeone FA, editor.
The Spine. Philadelphia: Saunders, 1992;
1343-52.

22. Browder J, Meyers R. Infections of the
spinal epidural space: an aspect of vertebral
osteomyelitis. AmJ Surg 1937;37:4-26.

23. Russel AN, Vaughan R, Morley TP. Spinal
epidural infection. Can J Neurol Sci 1979;
6:325-8.

24. Teman AJ. Spinal epidural abscess: early
detection with gadolinium magnetic
resonance imaging. Arch Neurol 1992;
49:743-6.

25. Garrido E, Rossenwater RH. Experience
with the suction-irrigation technique in the
management of spinal epidural infection.
Neurosurgery 1983;12:678-9.

26. Fischer EG, Greene CS Jr, Winston KR.
Spinal epidural abscess in children.
Neurosurgery 1981;9:257-60.

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NOVEMBER 1994, VOL. 90 471

An overview of adulthood attention deficit
hyperactivity disorder

TIMOTHY LESACA, M.D.

Psychiatrist, The Staunton Clinic, Pittsburgh;
and Assistant Clinical Professor of Psychiatry,
Medical College of Pennsylvania, Allegheny
Campus

Abstract

Attention deficit hyperactivity
disorder (ADHD) in adulthood has
become an increasingly recognized
and clinically significant psychiatric
syndrome. This article reviews the
criteria for diagnosing adulthood
ADHD, secondary > complications of
the disorder, and pharmacological
methods for treating this disorder.

Introduction

Attention deficit hyperactivity
disorder (ADHD) is a behavioral
disturbance characterized by
inattentiveness, impulsivity, and
hyperkinesis. Although historically
considered by clinicians to be limited
to childhood, evidence now suggests
that ADHD symptoms persist into
adulthood to a significant degree (1,2,3).

Retrospective and prospective
research studies indicate that between
31% and 66% of adults with a history
of childhood ADHD continue to have
symptoms of the disorder (4). Since
the prevalence of ADHD among
school-age children may be 3% or
more, ADHD may be found in at least
1% to 2% of adults (5).

Attention deficit hyperactivity disorder
can negatively impact many areas of
adult functioning. Compared to matched
controls, adults with a history of
childhood ADHD have lower self-
esteem, less formal education, and
inferior work records (6). The potentially
high prevalence of ADHD in the adult
population and its negative implications
upon adult functioning underscores the
importance of educating all health care
providers about this syndrome.

This article describes the criteria for
diagnosing adulthood ADHD,
concurrent psychopathology, and
treatment with an emphasis on
psychopharmacology.

Diagnosis

Despite attempts by researchers to
validate the diagnosis of adulthood
ADHD, the syndrome remains a
diagnostic orphan for several reasons.

First, many clinicians who treat
adults believe that ADHD always
disappears by adolescence, so they do
not consider it in adult treatment
settings (7). Secondly, the process of
retrospectively establishing a diagnosis
of childhood ADHD based upon the
patient’s ability to recall symptoms
that occurred many years previously,
has dubious reliability (7,8). Finally,
the DSM-III-R (9) criteria for the
diagnosis of ADHD includes many
behaviors specific for children, such as
“difficulty playing quietly, intrudes
into other children’s games, difficulty
awaiting his/her turn in games,” and,
therefore, does not differentiate
between ADHD in childhood versus
adulthood.

Although not yet recognized as a
tool for clinical office practice, Paul
Wender, M.D., and associates at the
University of LJtah have devised
research criteria for identifying adults
with ADHD for the purpose of
conducting pharmacological studies.
These criteria, referred to as the “Utah
criteria,” first require the establishment
of a history of ADHD in childhood,
and secondly, the presence of the
following two characteristics in
adulthood:

1 . Persistent motor hyperactivity

such as the inability to relax,
inability to persist in sedentary
activities like reading or watching
television, and dysphoria when
inactive.

2. Attention deficits manifested by
the inability to keep one’s mind
on a conversation, reading
materials, or his/her job; and also
distractibility and forgetfulness
demonstrated by actions such as
losing or misplacing items.

In addition, at least two of the
following characteristics must be
present to diagnose ADHD according
to the Utah criteria by Wender and his
associates:

1. Affective lability with mood
swings over hours to a few days
that range from being bored and
discontented to being excited.

2. Inability to complete tasks
which includes a lack of
organization at work or at home,
the inability to solve problems,
manage time, and concentrate on
one task at a time.

3. Temper problems such as being
irritable, easily provoked, and
explosive.

4. Impulsivity such as non-reflective
decision making, which also results
in turbulent work performance
and personal relationships,
antisocial behaviors and reckless
pleasure -seeking activities.

5. Low tolerance for stress which
results in depression, anxiety,
confusion or anger from just
having to deal with typical
everyday situations.

According to the Utah criteria, the
diagnosis of ADHD is preempted by
diagnoses of schizophrenia, schizo-
affective disorder, primary affective
disorder, and schizotypal or borderline
personality disorder (10).

Concurrent psychopathology

In a profile of 36 adults (ages 19 to
65 years) who met the Utah criteria for
ADHD, Skekim and colleagues (2)
found that 53% of the adults also met
criteria for generalized anxiety
disorder, 34% for alcohol abuse or
dependence, 30% for daig abuse, 25%
for dysthymia, and 25% for cyclothymic
disorder. Only 14% of the adults had
the diagnosis of ADHD alone, and
one third had four DSM-III-R
diagnoses in addition to ADHD. Also,
ADHD appears to be a frequent
underlying factor in the development
of pathological gambling (11,12).

Many outcome studies have found
that ADHD in childhood can lead to
antisocial behaviors in adulthood
(6,13). Studies differ greatly, however,
on the percentage of adults who are
antisocial (ranging from 10%-55%),
and on the severity of the antisocial
behaviors (3). The connection between
ADHD and antisocial disorders in adults
appears to be indirect, but it has been
shown that aggressive behaviors are
the most common way that antisocial
tendencies manifest themselves (14).

Bellack and colleagues (15)
advanced the hypothesis that certain
psychoses in adults evolve from
ADHD, secondary to an impact upon
social and cognitive development so
extreme as to produce disturbances in
reality testing, self-image and judgment.
These ADHD-related psychoses are
often misdiagnosed as schizophrenia
or an affective disorder, precluding
appropriate clinical intervention.

472 THE WEST VIRGINIA MEDICAL JOURNAL

Treatment

The treatment of adults with ADHD
can be divided into pharmacological
and non-pharmacological interventions.
Several controlled studies exist which
explore the efficacy of various
medications, but controlled studies of
non-pharmacological treatments have
not been conducted. The importance
of non-pharmacological treatments
should not be undervalued, however,
considering the significant complications
associated with this disorder. Through
psychotherapy, problems like low
self-esteem, emotional and social
isolation, feelings of rage,
procrastination, and avoidance of
difficult tasks can be addressed in a
constructive manner (5).

Methylphenidate is the recognized
first-line pharmacological intervention
for adulthood ADHD, and is thought
to act by increasing the concentrations
of dopamine and norephinephrine at
the synaptic cleft (5). Wender et al
(16) entered 37 adult patients meeting
Utah criteria for ADHD into a double-
blind crossover trial of methylphenidate
versus placebo. Therapeutic
improvement occurred in 57% of the
patients receiving methylphenidate
compared to only 11% of those
receiving placebo. The patients who
responded to methylphenidate
showed significant improvement in
the areas of impulsivity, attentional
difficulty, motor overactivity, and
affective lability. The final dosage
range for methylphenidate was 10-80
milligrams/day.

Gualtieri et al (17) conducted a
similarly designed study of 12 adult
male patients with ADHD using a
methylphenidate dose of 0.3
milligrams/kilogram b.i.d., and
observed an improvement in
concentration and a decrease in
restlessness compared to placebo.
However, the findings of this study
and those of Wender are contrary' to
the results of research by Mattes and
colleagues (18), who conducted a
double-blind crossover design study
of methylphenidate with 26 adult
patients with a childhood history of
ADHD. Their findings revealed no
overall benefit in taking
methylphenidate when compared to a
control group of 35 adults without a
history of ADHD. More controlled
studies of methylphenidate are
needed before its therapeutic efficacy
in adulthood ADHD can be clearly
determined.

Other stimulant medications with
possible applications for adulthood

ADHD include d-amphetamine and
pemoline. To date, no controlled trials
of d-amphetamine have been
conducted, although, it does have a
potential advantage over
methylphenidate due to a longer
duration of action. Pemoline has been
studied in the treatment of adulthood
ADHD and found to be more effective
than a placebo, but its clinical use is
hampered by a relative shortage of
controlled studies demonstrating
efficacy; a side effect profile that
includes agitation, headache and
insomnia; and a 2%-3% incidence of
the development of elevated liver
enzymes (10).

The clinically recognized second
line of drug treatment for adulthood
ADHD has up until recently been the
tricyclic antidepressants imipramine
and desipramine (19). A review of the
current literature reveals a surprising
lack of controlled studies on the use
of tricyclics for adulthood ADHD.
However, another medication which
has received increasing interest is the
antidepressant bupropion.

Wender and Reimherr (20) prescribed
an open trial of bupropion for 19
adults with ADHD and found that 14
of the adults experienced significant
benefit, and 10 of these patients
preferred to continue this medication
instead of starting back on their
previous treatment of stimulants or
monoamine oxidase inhibitors. The
authors theorize that bupropion's
efficacy is based upon its dopaminergic
activity. The mean dose of bupropion
for the 14 adults who experienced
benefit was 359 milligrams/day, with a
dosage range of 150-450 milligrams/day.

Several other medications have
been used to treat adulthood ADHD,
with varying results. The monoamine
oxidase inhibitors pargyline and
L-deprenyl have been studied, but
were found to have limited therapeutic
benefits, particularly when compared
to stimulants (21). Propranolol was
found to decrease the frequency of
temper outbursts and other symptoms
of ADHD in a trial of 13 adults, which
sugggests a need for more controlled
studies (22). The anxiolytic buspirone
has also been postulated as a useful
treatment based upon its presynaptic
dopamine antagonist properties which
increase the firing rate of midbrain
dopaminergic neurons, and thus
increase dopamine concentration at
the synapse (23) In addition,
fluoxetine, clonidine, thioridazine,
carbamazepine and lithium carbonate
have been shown to have some efficacy
in treating adulthood ADHD (24).

Conclusion

Adulthood ADHD is an increasingly
recognized syndrome with great
potential to disable many facets of an
adult’s life. Prompt diagnosis and
appropriate intervention are the
greatest weapons against the
damaging effects of this disorder.

References

1. Satin MS, Winsberg BG, Monettei CH. et al.
A general population screen for attention
deficit disorder with hyperactivity. J of the
Amer Acad of Child Psychiatry 1985;6:756-64.

2. Shekim WO, Asarnow RF, Hess E, et al. A
clinical and demographic profile of a
sample of adults with attention deficit
hyperactivity disorder, residual state.
Comprehensive Psychiatry 1990;31:416-25.

3. Weiss G. Followup studies on outcome of
hyperactivity children. Psychopharmocology
Bulletin 1985:21:169-77.

4. Denckla MB. Attention deficit hyperactivity
disorder-residual type. J of Child Neurology
1991:6 (Suppl):S44-S50.

5. Bellack L. Black RB. Attention-deficit
hyperactivity disorder in adults. Clinical
Therapeutics 1992;14:138-47.

6. Weiss G. Hechtman L. Milroy T, et al.
Psychiatric status of hyperactives as adults.

A controlled 15-year follow-up of 63
hyperactive children J of the Amer Acad of
Child Psychiatry 1985:24:211-20.

7. Biederman J. Faraone SV, Spencer T, et al
Patterns of psychiatric comorbidity, cognition,
and psychosocial functioning in adults with
attention deficit hyperactivity disorder. The
Amer J of Psychiatry 1993; 50:1792-8.

8. Loeber R. Green SM, Lahey BB. et al. Optimal
informants on childhood disruptive behaviors.
Development and Psychopathology 1989:
1:317-37.

9. American Psychiatric Association.

Diagnostic and statistical manual of mental
disorders. Washington, DC: 1987.

10. Wender PH. Wood DR. Reimherr FW.
Pharmacological treatment of attention
deficit disorder, residual type (ADD. RT,

Minimal brain dysfunction," hyperactivity")
in adults. Psychopharmacology Bulletin
1985:21:222-30.

11. Carlton PL. Manowitz P, McBride H, et al.
Attention deficit disorder and pathological
gambling. J of Clinical Psychiatry 1987;
48:487-8.

12. Carlton PL, Manowitz P. Behavioral restraint
and symptoms of attention deficit disorder
in alcoholics and pathological gamblers.
Neuropsychobiology 1992;25:44-8.

13. Hectman L, Weiss G. Controlled prospective
fifteen year follow-up of hyperactives as
adults: non-medical drug and alcohol use
and anti-social behavior. Can J of Psychiatry
1986:31:557-67.

14. Cadoret RJ, Stewart MA. An adoption study
of attention deficit/hyperactivity/aggression
and their relationship to adult antisocial
personality. Comprehensive Psychiatry
1991:3273-82.

15. Beliak L, Kay SR, Opler LA. Attention deficit
disorder psychosis as a diagnostic category.
Psychiatric Developments 1987;5:239-63-

16. Wender PH. Reimherr FW, Wood D, et al. A
controlled study of methylphenidate in the
treatment of attention deficit disorder,
residual type, in adults. The Amer J of
Psychiatry 1985:142:547-52.

17. Gualtieri TC, Ondmsek MG. Finley C.
Attention deficit disorder in adults. Clinical
Neuropsychopharmacology 1985;8:343-56.

NOVEMBER 1994, VOL. 90 473

18. Mattes JA, Boswell L, Oliver H.
Methylphenidate effects on symptoms of
attention deficit disorder in adults. Arch
Gen Psychiatry 1984;41:1059-63.

19. Satel S, Southwick S, Denton C. Use of
imipramine for attention deficit disorder in
a borderline patient. J of Nervous and
Mental Disease 1988:176:305-7.

20. Wender PH, Reimherr FW. Bupropion
treatment of attention-deficit hyperactivity
disorder in adults. Am J of Psychiatry 1990;
147:1018-20.

21. Wood DR, Reimherr FW, Wender PH. The
use of L-deprenyl in the treatment of
attention deficit disorder, residual type.
Psychopharmacology Bulletin 1983;19:627-9-

22. Mattes JA. Propranolol for adults with temper
outbursts and residual attention deficit
disorder. J of Clinical Psychopharmacology
1986;6(5):299-302.

23. Balon R. Buspirone for attention deficit
hyperactivity disorder. J of Clinical
Psychopharmacology 1990;10(1):77.

24. Sabalesky DA. Fluoxetine in adults with
residual attention deficit disorder and
hypersomnolence. J of Neuropsychiatry
1990;2:463-4.

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474 THE WEST VIRGINIA MEDICAL JOURNAL

A spontaneous esophageal perforation and duodenal
ulcer perforation resulting in a subpulmonic abscess

JAMES F. O’NEAL, M.D.

Assistant Professor, Department of Medicine,

Robert C. Byrd Health Sciences Center of West

Virginia University, Charleston Division,

Charleston

Abstract

Both spontaneous esophageal
perforations (Boerhaave syndrome)
and duodenal ulcer perforations are
medical emergencies. Spontaneous
esophageal perforation (SEP) is the
most serious and rapidly lethal
perforation of the gastrointestinal
tract. Prompt diagnosis and early
therapy is needed to prevent death
or prolonged serious illness, and the
key to the diagnosis is an awareness
of its frequent atypical presentations.
This article presents a case report
of SEP and duodenal ulcer perforation
which caused a right-sided
subpulmonic abscess and reviews
the literature pertaining to this
subject.

Case report

A-36-year-old man presented to the
emergency room with a two-week
history of fever, chills, night sweats,
non-productive cough, shortness of
breath, and right-sided pleuritic chest
pain. He had been seen at a clinic 10
days earlier and was diagnosed with
“pneumonia.” Three days prior to
arriving at the emergency room, his
stools became “loose and tarry.”

This patient had a temperature of
38.8°C and he had an orthostatic drop
in blood pressure. Chest examination
revealed lower zone dullness to
percussion and decreased breath
sounds bilaterally. Mild right upper
quadrant abdominal tenderness was
noted, but there was no rebound or
guarding. Stool tested positive for blood.
Other blood work showed his white
blood cell count was 34.5 with 63%
neutrophils and 19% bands; and his
hemoglobin was 6.7 gm/dl, hematocrit
19.7%, with a platelet count 1,191.

The chest radiograph (Figure 1)
revealed a large air-fluid structure at
the right lung base which was
confirmed by thoracic computerized
tomography, so broad spectrum
antibiotics were prescribed. Under
computerized tomography guidance,
percutaneous drainage of the fluid was

performed (Figure 2), and the fluid
culture revealed beta Streptococcus,
group C. Bronchoscopy showed no
abnormalities.

After the patient had been stabilized,
further history revealed that he had been
drinking alcohol and had vomited
three times prior to the initiation of his
symptoms. A perforation was
considered; however, gastrografin
swallow did not reveal any
communication between the right lung
base, esophagus and stomach.
Esophagogastroduodenoscopy showed
two duodenal ulcers located
posterolaterally at the junction of the
first and second portion of the
duodenum.

This patient was initially felt to have
a right lung abscess, and despite
therapy, he continued to have fevers
to 39°C with a leukocytosis of 20.0. A
right thoracotomy was performed
which revealed normal pulmonary
parenchyma and a subpulmonic
abscess extending across the
mediastinum into the abdomen. In
addition, intraoperative
esophagogastroduodenoscopy
demonstrated a distal esophageal
perforation.

The right thoracotomy incision was
closed and a left thoracoabdominal

incision was made. A perforation of
the posterolateral duodenal ulcer was
found which tracked superiorly into
the lesser sac. An inflammatory
reaction behind the portal vein
leading towards the thorax was noted.
A vagotomy and pyloroplasty were
performed in addition to an omental
patch repair of the distal esophagus.

Figure 1. Posteroanterior chest radiograph
shows an 8 cm. ovoid cavity with
air-fluid level at the right lung
base. There is also a left pleural
effusion.

Figure 2. Thoracic CT scan with percutaneous catheter lying within an abscess cavity at the
right lung base.

NOVEMBER 1994, VOL. 90 475

After a complicated hospital course,
this patient was discharged in stable
condition and he has done well at 15
months in follow-up.

Discussion

This is a rare case in which the
patient had both a spontaneous
esophageal perforation (Boerhaave’s
Syndrome) and a perforation of an
intra-abdominal viscus in the
duodenum, which caused abscess
formation in the right thoracic cavity.

SEP was first described in 1724 by
the Dutch physician Boerhaave. He
described a patient who developed
sudden excruciating chest pain while
straining to vomit, and then went into
shock and died (1). The first
successful surgical repair was
performed in 1946 by Barrett (2).

History is of paramount importance
and the classic presentation is of a
middle-aged man, often with a
background of alcoholism or dietary
excess, presenting with these
symptoms:

1) vomiting

2) lower thoracic pain

3) subcutaneous emphysema

These three symptoms have been

classified as Mackler’s Triad (3). To
this triad may be added
pneumomediastinum, or the presence
of air-fluid in the pleural cavity.

Although SEP is classically post
emetic, there are numerous reports of
it occurring without vomiting or pain.
This condition has been found to
occur as a result of asthma, childbirth,
sleep, a food binge, laughter, heavy

lifting, prolonged coughing, hiccups,
straining at stool, or after the Heimlich
maneuver and trauma.

Review of the medical literature
reveals that SEP continues to be
frequently missed. Approximately one
third of all cases are clinically atypical
(4). The most common initial
misdiagnoses include myocardial
infarction, pneumonia, pancreatitis,
lung abscess and pulmonary
embolism (5).

Chest radiographs should not be
depended upon to diagnosis SEP (6).

A helpful finding is mediastinal
emphysema. Unfortunately, this takes
approximately one hour to develop
and is present in only 40% of the
patients with SEP. In adults, two-thirds
of the perforations occur on the left
side, 20% on the right, and 10%
bilaterally (7). The diagnosis is usually
confirmed by a contrast study of the
esophagus showing extravasation, but
10% of these studies may be falsely
negative (8). The examination should
be repeated if clinical suspicion is
high, and the treatment of choice is
surgical closure of the perforation
within 24 hours. After 24 hours,
survival decreases to less than 50% (9).

Although SEP is uncommon, it is
not rare. Unfortunately the proportion
of undiagnosed cases discovered at
autopsy remains high. Improvements
in medical technology have not been
paralleled by increasing diagnostic
accuracy (10). Clinicians need to be
alert to this lethal disease and be
aware of its frequent atypical
presentations.

References

1. Barrett NR. Spontaneous perforations of the
oesophagus: review of literature and report
of three new cases. Thorax 1946;1:48-70.

2. Barrett NR. Report of a case of spontaneous
perforation of the oesophagus successfully
treated by operation. Br J Surg 1947;35:216-8.

3. Mackler SA. Spontaneous rupture of the
esophagus. An experimental and clinical
study. Surg Gynecol Obstet 1952;95:345-56.

4. Loop FD, Groves LK. Esophageal perforations
(collective review). Ann Thorac Surg 1970;
10:571-87.

5. Bladergroen MR, Lowe JE, Postlethwait RW.
Diagnosis and recommended management
of esophageal perforation and rupture. Ann
Thorac Surg 1986;42:235-43.

6. Brahams D. Medicine and the law: failure to
detect radiological signs of ruptured
esophagus. Lancet 1986;11:232-3-

7. DeMeestar TR. Perforation of the esophagus
(editorial). Ann Thorac Surg 1986;42:231-2.

8. Findley RJ, Pearson FG, Weisel RD, et al.
The management of non-malignant
intrathoracic esophageal perforations. Ann
Thorac Surg 1950;30:575-81.

9. Light RW. Exudative pleural effusions
secondary to gastrointestinal diseases. Clin
Chest Med 1985;6:103-11.

10. Goldman L, Faison R, Robin R, et al. The
value of the autopsy in three medical eras.

N Engl J Med 1983;308:1000-5.

Manuscript Guidelines

All scientific manuscripts should be submitted on an IBM
compatible disc in Wordperfect 5.1 or in ASCII (generic).
They must be prepared in accordance with “Uniform
Requirements for Manuscripts Submitted to Biomedical
Journals. ”

All manuscripts should include:

1 . Title page

2. An abstract of no more than 150 words

3. Text

4. Acknowledgements

5. References in parentheses numbered consecutively. No
more than 25 references will be published free of cnarge.

6. Tables

7. Legends for illustrations

All persons designated as authors should qualify for
authorship. Each author should have participated sufficiently
in the work to take public responsibility for the concept.

Where reference is made to generically-designated drugs,
the first such reference must be followed by parentheses
containing its most commonly known trade name.

All scientific material is reviewed by the Publication
Committee and should be sent to The Editor, West Virginia
Medical Journal, P.O. Box 4106, Charleston, WV 25364.

476 THE WEST VIRGINIA MEDICAL JOURNAL

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Stability ret urns to tbe medical liability insurance market. In nine states
18,000 of our' member-insnred doctors have been enjoying the new cost
climate. Protected by one of the largest medical professional liability
monoline insurance companies in America. And defended by a firm of
medically sawy litigators who close almost 80% of cases without payment.
Arid, year in and out, win 90% of those that go to trial.

For information, call 1-800-228-2335.

RMI, Ltd.

910 Quanier
Charleston, \V V 25324
304-346-3024

THE P-I-E MUTUAL
INSURANCE COMPANY

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1001 Lakeside Avenue
Cleveland, Ohio 44114
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304-723-4600

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700 Ann Street
Parkersburg, WV 26102
304-485-5569

Even though I look nothing like
Uncle Sam on the old recruiting
poster (except for the fact that my hair
is rapidly turning white), his words “I
want you!" express exactly how I feel.

You may wonder what it is that
you're needed for — after all, your
practice is busier than ever, your golf
game is finally coming around, and
that pesky specter of national health
care reform is a bitter but rapidly
fading memory. Not only that, but
you’ve elected me as your president
to watch over and take care of any
little problems that arise. I thank you
for your trust and support but, ennui
and complacency are our biggest
enemies.

I want you now, not tomorrow or
next year, to become INVOLVED.

Yes, I know this is a frightening
concept for some of you, but I would
like each and every one of you to sit
down and think about what you as an
individual, and what we as a group,
can do to improve the future of our
profession. It is in YOUR HANDS, not
mine, that this future is held. I will be
your spokesman, your weapon in the
ongoing fight against the enemies of
our profession and most importantly,

President’s Page

“I want you!”

our patients. But, I cannot and will
not do it without your help.

Significant problems loom on the
horizon. Managed (or more
appropriately rationed) care is rapidly
moving into our state, sometimes, and
I find this hard to believe, with the
assistance of our members. State
government is also starting to socialize
the medical care system it controls
(PEIA, Medicaid, Worker’s
Compensation, etc). In addition, this
administration seems intent on
producing a health care bill with little
or no input from us -- the physicians
who actually provide the health care
for our citizens. If this doesn’t scare
you it should.

I want you to be involved and I
want to be effective. Divisiveness and
cacophony will have no place during
my presidency. Call me old fashioned,
but a house divided cannot stand. WE
WILL SPEAK IN UNITY ON EVERY
ISSUE OR WE WILL FAIL. This is not
to say there will be no discussion or
dissent, but it will be in the proper
forum and not in the press or public.

I want you to be more active in
your communities, in your component
societies, the WVSMA, and in the

political process. Talk to your
patients, your friends, and your
politicians. Let them know how you
feel about the issues surrounding our
profession. But, and I can’t emphasize
how important this is, listen to and be
interested in what they have to say;
otherwise your message will fall on
deaf ears. And, most surprisingly, you
may learn something that may help
you understand why people feel so
strongly about this thing called
medical care.

Please, help me preserve and
enhance the practice of medicine in
West Virginia.

Dennis M. Burton, M.D.

P.S. IF YOU DON’T BECOME

INVOLVED, DON’T BOTHER
TO CALL ME LATER AND
COMPLAIN ABOUT THE
OUTCOME.

478 THE WEST VIRGINIA MEDICAL JOURNAL

Editorials

Access to medical care

Our first feature article this month,
“ Access to Medical Care in West
Virginia: Implications for Policy, ”
offers an opportunity to examine
health system research, its potential
value and its potential for misleading
conclusions. Throughout this article,
the authors are quite candid in
pointing out the limitations of the
studies cited, but the studies lend
themselves to easy out-of-context
quotes which lead to distortions of
their actual findings.

The studies make no distinction
between emergency care and any
other type of medical care so that we
do not know what the individuals
polled regarded as needed or
desirable. Is it chiropractic care they
feel was needed and unprovided, or
some form of “alternative” care?

Perhaps it was for a problem the
benign neglect of which would have
produced a cure as quickly and at a
significant cost savings to our total
national health care bill. Many, many
misplaced and inappropriate items
appear beneath the rubric medical
care costs. A good argument can be
made that beyond emergency medical
care, further elements down the list of
medical care possibilities very quickly
become luxury or optional items.

There were several mildly surprising
and reassuring findings about West
Virginia brought out in the several
polls. Among these is the finding that
far from being neglected, Medicare
recipients in rural West Virginia have
as many or more hospital visits and
procedures as their urban counterparts.
Another interesting finding reveals that

The election

“The morning after” can connote
either a thumping headache, nauseous
feelings in the stomach, regrets over
the previous night’s activities or the
pleasant recall of recent pleasurable
orgiastic experiences. The morning of
November 9th provided occasion for
both, depending on which political
party one happens to espouse.

That day also provided occasion for
political pundits of the media and
both political parties to explain the
previous day’s events. All appeared
defeated by the task. There appeared
to be unanimity that the electorate had
sent a message that it wanted
“change.” That same explanation

seems to have accounted for the
results of every election for perhaps as
long as we have had elections.

It seems far more likely that the real
message from the voters is that they
have endured far too many changes in
recent years, and that most of these
have been disappointing at best. I
think the unspoken message is that it
is time to reflect on tradition and
history, our family and cultural values;
time to stop trendy, politically correct
edicts; and time to compare what we
appear to be acquiring in this nation
with what we have had in the past.

It is perfectly clear, as most of the
pundits seemed to grasp, that the

health service statistics in West
Virginia do not vary in any significant
way from those found nationally. The
results of the health care reform
debate during the past year suggest
that these statistics are acceptable to
the great majority of Americans.

We certainly agree with one of the
concluding comments in this article
“...health services research is in its
infancy and survey data requires
cautious inteipretation. "We also
totally agree with and endorse the
final paragraph, “As West Virginians
develop health reform policies,
policymakers should avail themselves
of the best research available and
thoughtfully consider the implications
of contradictory policy initiatives. ”

- SDW

American people have had enough of
the paternalistic and intrusive efforts
of our federal government to further
dominate our lives. In this respect, a
clear message has been sent to those
political professionals in the habit of
responding attentively to every
instruction of Liberal gums. No
politician can afford to miss that
message.

In West Virginia, we happily note
an early beginning at acquiring some
semblance of badly needed political
balance for our state.

- SDW

NOVEMBER 1994, VOL. 90 479

Our Readers Speak

A difference of opinion on endorsements

Like other states with low levels of education, high
union affiliation and a constant exposure to class warfare,
Republican candidates often perform frustratingly less than
satisfactorily in West Virginia. Your calling the party
“impotent” in the West Virginia Medical Journal may be a
bit strong however.

One of our greatest impediments in building a stronger
political balance is our inability to persuade interest
groups like the WVSMA from endorsing the very same
legislators who have opposed the medical profession.
Groups like yours argue that through their contributions
perhaps the liberal Democrat leadership won’t be too
harsh on them. Haven’t you all learned anything from
history? Isn’t there a psychological term for this?

The following selections are incumbents endorsed by
the WVSMA even though their voting records on 10
medical issues were 33% or less. Two times out of three
times they opposed your position! These issues were
selected in concert with the WVSMA:

District

Incumbent

Leadership in House

1st

Tamara Pettit

30%

4th

Scott Varner

5th

David Pethtel

Vice Chairman -
Constitutional Revision

15th

Margaret Leach

16th

Steve Williams

30%

Chairman - Banking

17th

Kenneth Adkins

33%

19th

Larry Heck

10%

27 th

Robert Kiss

Chairman - Finance

30th

Joe Farris

10%

37th

Joe Martin

Chairman -

Government

Organization

37th

Bill Proudfoot

20%

44th

Robert Beach

Chairman - Agriculture

46th

David Collins

Vice Chairman -
Political Subdivision

Only by working in a coordinated effort with affected
groups can we achieve political balance in this state. We
have had soloists sing their song and get some
recognition; but imagine the difference if we had a choir.
Many of us are committed to achieve that objective.

Recently, I addressed the WVSMA Alliance in Ohio
County. There I listed several planks on which we find
mutual agreement:

• Tort reform

• Individual accountability for personal lifestyles and
choices, i.e. obesity, smokeless tobacco, sedentary
lifestyle and teenage pregnancies

• Elimination of Medicaid tax on all providers

• Insurance reform

• Violence within our families and threats to our
children

During these remarks, I alluded to my ongoing evaluation
of a 1996 gubernatorial race. Mary and I have crisscrossed
the state in an effort to ascertain whether a conservative
businessman and yes, a Republican, can win. In addition,
we have already hired one staff person and two nationally
recognized consultants. You seem to have concluded that
our party is incapable of grasping this goal; nevertheless, I
would appreciate the opportunity to dissuade you.

Let me also congratulate your bold editorial statement in
the October issue of the West Virginia Medical Journal.
There are ample reasons "to break all ties with the
Democratic Party. ” We need to be prepared to be the
alternative.

Thank you for your political insight.

David B. McKinley
Wheeling

50th Jerry Mezzatesta 0% Majority Whip

480 THE WEST VIRGINIA MEDICAL JOURNAL

Interactions

Medical Staff Leadership Conference — January 13-15, San Antonio, Texas

Health system reform might seem like a never-ending battle,
but with leadership, vision, and perseverance, you and your
medical staff can overcome any obstacle. Learn what it takes
to succeed in today’s rapidly changing environment. Come to
Interactions in beautiful San Antonio, Texas, January 13-15.

Experience a new way of thinking
about the future.

This year’s conference, “Physician Empowerment and
Teamwork in a Changing Environment,” will help you
experience a change of perspective on the 21st Century.

Learn how to manage change.

During Interactions, we will address emerging trends in
health care delivery and how best to manage them. Among
the trends we will discuss are:

• Physician/hospital • Physician autonomy

relationships • Resource allocation

• Economic competition • Regulatory constraints

Gain new leadership skills.

Special emphasis will also be placed on developing and
refining your strategic planning, team building, and com-

munication skills. Each participant will learn how to be a
more effective arbitrator, facilitator, manager, negotiator,
problem solver, and peacemaker.

Your team leaders.

Who should attend.

For more information or to register, call 800 621-8335.

The AMA designates the interactions conference for 18
credit hours of Category 1 of the Physician’s Recognition
Award of the AMA.

American Medical Association

Physicians dedicated to the health of America

General News

At Mid-Winter

WV-ACP/WVSMA co-sponsored session
to highlight “Moving Points in Medicine ”

This year’s First Scientific Session,

“ Moving Points in Medicine," at the
WVSMA’s Mid-Winter Clinical
Conference will again be co-sponsored
by the West Virginia Chapter of the
American College of Physicians and
will be presented on Friday, January 20
at 1:30 p.m. at the Radisson Hotel in
Huntington. This session will feature
five speakers and will be moderated by
Robert J. Marshall, M.D., F.A.C.P.,
governor of the WV-ACP.

The first scheduled lecturer for this
program will be Lawrence Frohman,
M.D., F.A.C.P., the Edmund F. Foley
Professor and head of the Department
of Medicine at the University of Illinois,
who will discuss the “ Use of Growth
Hormone in the Adult and Aging
Population. 'The next speaker, Craig J.
McClain, M.D., director of the Univer-
sity of Kentucky’s General Clinical
Research Center, will describe “New
Concepts in Gastroesophageal Reflux
and Ulcer Disease. ’’Following Dr.
McClain’s presentation, Maurice A.
Mufson, M.D., professor and chairman
of the Marshall University School of
Medicine, will speak on the subject of
“ Lessons Learned from Vaccine Use
During the Past 40 Years." This session
will then conclude with a special
lecture: “ Peripatetic Plastic Surgeons:
Benefactors of Mankind or Innocents
Abroad?” which will be delivered by
plastic and reconstructive surgeons
F. Anthony Wolfe, M.D., and Deirdre
M. Marshall, M.D., of Miami.

Information about these speakers
begins below. A registration form for the
Mid-Winter Clinical Conference appears
on page 487, and more details about the
meeting can be obtained by phoning
Nancie Diwens at (304) 925-0342.

Session presenters highlighted

Dr. Frohman is a graduate of the
University of Michigan Medical School
and received training in internal
medicine at Yale-New Haven Medical
Center and in endocrinology at Duke
University Medical Center.

Mufson

Before accepting his current post in
1992 as the Edmund F. Foley Professor
and head of the Department of
Medicine at the LJniversity of Illinois, Dr.
Frohman was director of endocrinology
and metabolism at the University of
Cincinnati, where he was also director
of the General Clinical Research Center.
During his career, he has also held
faculty positions at the State University
of New York at Buffalo and the
University of Chicago/Michael Reese.

Dr. Frohman’s research has been
supported by the NIH for the past 27
years, and his work has included
studies of the neuroendocrine
regulation of pituitary function,
particulary on the hypothalmic control
of growth hormone (GH) secretion. His
laboratory was the first to document
hypothalamic control of GH secretion,
provide evidence for a hypothalamic
GH-releasing factor, and to identify and
characterize this factor in extra-pituitary
tumors associated with acromegaly.

The recipient of the Endocrine
Society’s Rorer Award for Excellence in
Clinical Investigation in 1991, Dr.
Frohman currently serves as the Bane
Scholar at the University of Illinois. I le
is the author of more than 300 scientific
publications, and is an editor of the
textbook Endocrinology and
Metabolism.

Dr. McClain is a graduate of the
University of Tennessee School of
Medicine. He completed his internal
medicine residency at the University of
Pittsburgh and a fellowship in
gastroenterology at the University of
Minnesota.

Wolfe Marshall

In 1982, Dr. McClain joined the
faculty of the LIniversity of Kentucky
as director of gastroenterology. He
assumed an additional role at UK in
1992 when he was named director of
the NIH-funded General Clinical
Research Center.

Dr. McClain has extensive research
interests and is involved with ongoing
projects involving micronutrients,
cytokines, eating disorders, ulcer
disease and metabolic abnormalities
in trauma and alcoholic liver disease.
He has published more than 120 peer-
reviewed manuscripts, as well as over
45 other articles and book chapters,
and is a reviewer for numerous
journals.

A speaker at many national and
international symposiums, Dr. McClain
received the Grace A. Goldsmith Award
for Outstanding Research in 1990.

Dr. Mufson is a native of New
York City who graduated from
Bucknell University in Lewisburg, Pa.,
and from the New York University
School of Medicine in New York City.
He served as an intern and resident
physician at Bellevue Hospital in New
York City and as chief resident
physician on the LIniversity of Illinois
College of Medicine Service at Cook
County Hospital in Chicago.

Dr. Mufson served with the U.S.
Navy Medical Corps from 1959-61. He
then became a Public Health Service
Post-Doctoral Fellow in Infectious
Diseases at the National Institutes of
Health in Bethesda, Md., and in 1962
joined the U.S. Public Health Service
as a commissioned officer.

Frohman

482 THE WEST VIRGINIA MEDICAL JOURNAL

In 1965, Dr. Mufson was appointed
to the faculty of the University of
Illinois College of Medicine, where he
taught for 11 years and attained the
rank of professor of medicine. Dr.
Mufson relocated to Huntington in
1976, to become the first professor and
chairman of the Department of
Medicine at the Marshall University
School of Medicine, where he has
received both the University Scholar
and the Meet-the-Scholar Award.

A fellow of the American College of
Physicians, Dr. Mufson is also a
fellow of the Infectious Diseases
Society of America and is a member
of numerous national medical
societies. He was a recipient of the
West Virginia Chapter of the American
College of Physicians’ Laureate Award
in 1994.

This past June, Dr. Mufson was a
visiting scientist in the Virology
Department of Karolinska Institute of
Medicine in Stockholm, Sweden.

Dr. Wolfe received his M.D. degree
from Harvard University in 1965. He
completed his internship at University
Hospitals of Cleveland, and then did a
residency in general surgery at Peter
Bent Brigham Hospital in Boston and
a residency in plastic surgery at the
University of Miami School of
Medicine.

Dr. Wolfe was awarded a Fulbright
Scholarship for 1974-75 and served as
an assistant to Paul Tessier, M.D., in
Paris. In 1974, he also joined the
faculty of the University of Miami
School of Medicine, where he is
presently a clinical professor of plastic
and reconstructive surgery.

A fellow of the American College of
Surgeons and a founding member of
the International Society of
Craniomaxillofacial Surgery, Dr. Wolfe
is a member of many other medical
organizations. He holds appointments
at seven hospitals in the Miami area,
and is a consultant in craniofacial
surgery at the University of Florida in
Gainesville and at the University of
Texas Medical Branch in Galveston.

A noted author and lecturer around
the world, Dr. Wolfe serves in editorial
capacities for Plastic and Reconstructive
Surgery, Annals of Plastic Surgery,
American Cleft Palate Journal, and
International Pediatrics.

Dr. Marshall is a native of
Morgantown who obtained a B.A.
degree in French literature from Yale
University in 1983 and then attended
Stanford University, where she received
her M.D. degree in 1987. She completed
an internship and residency in general
surgery and in plastic and reconstructive

surgery at Stanford from 1987-93.
During this time, she also completed a
fellowship in hand and microsurgery
at the Institut Francais de la Main in
Paris, and a fellowship in cosmetic
surgery with Dr. Lawrence Robbins in
Miami Beach.

Since July 1993, Dr. Marshall has
been in private practice in plastic and
reconstructive surgery in Miami, and
has also been a clinical instructor at
the University of Miami. She is on the
staffs of sLx Miami hospitals and this

year was named Attending Physician
of the Year by the Miami Children’s
Hospital Nurses Association.

Dr. Marshall is an associate fellow
of the American College of Surgeons
and was a founding member of the
American Society of Plastic and
Reconstructive Surgery’s Women’s
Caucus. Last year, Dr. Marshall was a
featured speaker at the Fifth Biannual
Meeting of the International Society of
Craniofacial Surgery in Oaxaca,
Mexico.

Physician/Public Session to
focus on managed care

“ Health Reform/Managed Care”
will be the title of this year’s
Physician/Public Session on Friday,
January 20 at 7 p.m during the
WVSMA’s Mid-Winter Clinical
Conference at the Radisson Hotel in
Huntington. Panelists for this
program will be Neil Schlackman,
M.D., medical director and vice
president of medical delivery for U.S.
Healthcare, and Michael Tanner,
director of health and welfare
studies with the Cato Institute in
Washington, D.C.

Dr. Schlackman is a Philadelphia
native who received his M.D. degree
from Hahnemann Medical College in
1968. He completed his internship
and residency, and also a fellowship
in pediatric-hematology at St.
Christopher’s Hospital for Children.

A major in the U.S. Air Force, Dr.
Schlackman was a pediatric
hematologist-oncologist at David
Grant Medical Center at Travis AFB
from 1971-73, during which time he
was also a clinical instructor of
pediatrics at the the University of
California at Davis. In 1973, Dr.
Schlackman returned to Pennsylvania
to open his private practice in
Sellersville and become a clinical
associate professor of pediatrics at
the Temple University School of
Medicine, a post he still holds today.

In 1986, Dr. Schlackman became
associate medical director of U.S.
Healthcare, a company which
operates managed care programs in
six states. He then left private
practice the following year when he
was promoted to his current
position as medical director and
vice president for U.S. Healthcare.

Schlackman

Mr. Tanner served as director of
research for the Georgia Public
Policy Foundation in Atlanta before
accepting his present role as director
of health and welfare studies with
the Cato Institute in Washington,

D.C. During his career, Mr. Tanner
also spent five years as legislative
director with the American
Legislative Exchange Council, where
he specialized in health and welfare
issues.

An adjunct scholar with The
Mackinac Institute in Michigan and
the Alabama Family Alliance, Mr.
Tanner is a contributing editor to
Intellectual Ammunition magazine.
He is the author of five books on
health care reform and is the author
of Children, Family, Neighborhood,
Community: An Empowerment
Agenda, a study of state welfare
reform.

The Physician/Public Session will
be moderated by WVSMA President
Dr. Dennis Burton. For more details
about this event or any of the other
Mid-Winter Clinical Conference
programs, phone Nancie Diwens at
(304) 925-0342. A registration form for
the meeting is printed on page 485.

Tanner

NOVEMBER 1994, VOL. 90 483

Medical College of Virginia offering
annual head/neck anatomy course

A four-day course entitled "The Alton D Brashear
Postgraduate Course in Head and Neck Anatomy '' will be
conducted from February 27 - March 2 at the Medical
College of Virginia in Richmond.

Lectures and demonstrations will augment the laboratory
work. This course is approved for 44 credit hours in
Category 1 of the Physician’s Recognition Award of the
AMA and the Academy of General Dentistry.

More information can be obtained from Dr. Hugo R.
Seibel, Department of Anatomy, P.O. Box 980709, Medical
College of Virginia, Richmond, VA 23298-0709.

University of Oklahoma sponsoring
22nd critical care conference

The University of Oklahoma’s 22nd Annual Critical Care
Medicine Course will take place from March 4-9 at the
Marriott Hotel in Oklahoma City, Okla.

The 48 CME credit hours offered at this meeting are
acceptable by the AMA, AAFP, AOA and ACEP.

Course Coordinator Dora Lee Smith can be contacted at
(405) 271-5904 for additional details.

Electronic patient records meeting
to take place in Orlando in March

The Medical Records Institute has announced plans for
“ Toward an Electronic Patient Record 95: Eleventh
International Symposium on the Creation of Electronic
Health Record Systems and Global Conference on Patient
Cards , "which will be presented at Disney’s Contemporary
Resort in Orlando, Fla., from March 14-19.

More than 80 companies will be exhibiting a variety of
electronic health record systems and products at the meeting.

Phone the Medical Records Institute at (617) 964-3923 for
more information.

Seattle site for national Children’s
Defense Fund annual seminar

The Children’s Defense Fund’s 1995 Annual National
Conference - - Leave No Child Behind: Building and
Strengthening Communities for Children will be held March
9-11 at the Washington State Convention and Trade Center.
Phone the CDF at (202) 662-3684 for details.

MOVING??

If you are a WVSMA member who will be
changing your office or home address, please
phone WVSMA Membership Coordinator Donna
Webb at (304) 925-0342 as soon as possible so
your Journal and other WVSMA mailings will not
be disrupted.

All other Journal subscribers who have address
changes should phone WVSMA Advertising
Manager Michelle Ellison at this same number.

Prescribing Prevention

U.S. Surgeon General Dr. Jocelyn Elders received many standing
ovations during her keynote address for the First International
Conference on Prevention, which was presented in Charleston
from October 27-30. In her speech. Dr. Elders discussed the need to
strengthen the nation’s public health system by focusing more
emphasis on “the three P’s - - Poverty , Population and Prevention. ”

CME symposium scheduled for
CLIA ’88 laboratory directors

The National Laboratory Training Network, Southeastern
Office is sponsoring a program entitled “ Symposium for CLIA
'88 Laboratory Directors" from March 9-11 at Wild Dunes, S.C.

The director for this course will be Tina Stull, M.D., of the
Centers for Disease Control and Prevention. A total of 13
CME units are being offered for the core curriculum and
another 1 1 CME units are being offered for optional courses.

For further details, phone the National Laboratory Training
Network at (800) 536-6586 (Southeast only) or (615) 262-6315.

Legislative Briefing, Reception set

The 1995 WVSMA Legislative Briefing and Reception has
been scheduled for Wednesday, February 8 at the
Charleston Marriott.

The briefing will begin at 5 p m. and the reception will
follow at 6:30 p.m. The WVSMA lobbyists will again be
updating members on legislation the WVSMA has
introduced and supported. Currently, the WVSMA Legislative
Committee is preparing its legislative package which will
include the Medical Savings Account proposal introduced
last year, tort refonn, and the Patient Protection Act.

Please mark your calendars now and plan to attend
these two important events. More details will be provided
in future issues of the Journal and WESGRAM.

484 THE WEST VIRGINIA MEDICAL JOURNAL

The Excitement is Snowballing...

Join us for the

1995 Mid- Winter Seminars and
Scientific Conferences

January 19-22, 1995

Radisson Hotel - Huntington
/

1995 Mid-Winter Registration Form

Name

Phone

Address

City State Zip Code

Payment by: Check Visa MasterCard

Card Number

Conference Cost: WVSMA member $125 _

non-member $175 _

Lunch & Learn Physician $50 _

spouse/student $35 _

TOTAL

Conomikes Thursday, January 19

9 a.m. - noon "Reception and Patient Flow Techniques'
(Lunch on your own)

Expiration Date

Signature

If paying by check, please send registration form and check to:

West Virginia State Medical Association

P.O. Box 4106
Charleston, WV 25364
(304) 925-0342

"Better Collections, Billing and Insurance Methods"

morning only $95

afternoon only $95

both sessions $185

TOTAL

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

Cabell County Medical Society -
Huntington

January 12

“Recognizing and Treating
Depression,” Jeff Kelsey, M.D.,
Gateway Holiday Inn, 6:30 p.m.

Robert C Byrd Health Sciences
Center of WVU - Charleston

December 1

(Teleconference) “LDLs and You,”
Shawn Chillag, M.D., noon

December 15

(Teleconference) ’’Medical Evaluation
of Sexually Abused Children,”
Kathleen V. Previll, M.D., noon

West Virginia State Medical
Association - Charleston

January 19-22

WVSMA’s Mid-Winter Clinical
Conference, Radisson Hotel,
Huntington

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Gassaway □ Braxton County Memorial
Hospital, Dec. 5, 6:30 p.m., “Lung
Carcinoma,” Rakesh Wahi, M.D.

Logan □ Logan General Hospital, Dec. 9,
11:45 a.m., “Gestational Diabetes in
Pregnancy,” David Chaffin, M.D.

Montgomery □ Montgomery General
Hospital, Dec. 7, TBA*

New Martinsville ★ Wetzel County
Hospital, Dec. 8, noon, “Laboratory
Tests in the Diagnosis of
Rheumatologic Diseases,” Jo Ann
Allen, M.D.

Parkersburg ★ Camden-Clark

Memorial Hospital, Dec. 7, 7:30 a.m.,
“Dystonia: What Is It and How Do
You Treat It?” Laurie Gutmann, M.D.

★ Camden-Clark Memorial Hospital,
Dec. 14, 7:30 a.m., “Estrogens: Risks
and Benefits,” Mark Gibson, M.D.

Richwood □ Richwood Area Medical
Center, Dec. 8, 5:15 p.m., “Cancer
Prevention Screening,” Arvind
Kamthan, M.D.

Ripley □ Jackson General Hospital,

Dec. 9, TBA*

Spencer □ Roane General Hospital,
Dec. 20, TBA*

White Sulphur Springs ★

Tire Greenbrier Clinic, Nov. 28,

4 p.m., “Disability Rating:
Contemporary Issues in West Virginia
Practice,” Janie Vale, M.D., M.S.P.H.

*To be announced

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486 THE WEST VIRGINIA MEDICAL JOURNAL

Poetry Corner

December

2-The 80th Scientific Assembly and Annual
Meeting of the Radiological Society of North
America, Chicago

8-9-Tools and Techniques for Improving
Clinical Outcomes: A Practical Seminar for
Physicians and Clinical Leaders (sponsored
by the Joint Commission on Accreditation of
Healthcare Organizations), Cincinnati

8- 10-National Conference on Community
Development (sponsored by the National
Rural Health Association), Minneapolis,

Minn.

10-The Eleventh Annual Clinical Update in
Pulmonary Medicine (sponsored by the
Deborah Heart and Lung Center), Atlantic
City, NJ.

10- 15-American Academy of Facial Plastic
and Reconstructive Surgery, Key Biscayne,
Fla.

January

20-21-Clinical Innovations in OB/GYN
Ultrasound (sponsored by Meetings &
Management Techniques Plus), San Antonio,
Texas

27— The Ethics and Law in West Virginia of
Health Care Decision Making for
Incapacitated Patients (sponsored by the
West Virginia Network of Ethics
Committees), Flatwoods, W.Va.

February

5- 8-Southem Surgical Congress, New
Orleans

6- 8-Cardiovascular Conference at Snowshoe
(sponsored by the American College of
Cardiology), Snowshoe, W.Va.

9- 12-50th Annual Postgraduate Ob/Gyn
Assembly (sponsored by the Ob/Gyn
Assembly of Southern California), Beverly
Hills, Calif.

11- 18-Super EMG XVI (sponsored by Ohio
State University), Kohala Coast, Hawaii
l6-19-American Academy of Pain Medicine,
Palm Springs, Calif.

16-21— American Academy of Orthopaedic
Surgeons, Orlando, Fla.
20-22-Cardiopulmonary Rehabilitation
Symposium: Status ’95 (sponsored by the
University of Florida), Orlando, Fla.
February 24-March 1-American Academy
of Allergy' and Immunology, New York City
February 27— March 2-The Alton D.
Brashear Postgraduate Course in Head and
Neck Anatomy (sponsored by Virginia
Commonwealth University), Richmond

For More Information . . .

Contact the Journal at (304) 925-0342.

Just Memories

You left memories
Of kind footprints
On my heart.

Your tread was light
And I thought that I might
Overcome my feelings from the start ,
But you left memories
Of kind footprints
On my heart.

You left memories
Of your laughter
In my mind.

We laughed a lot
And I thought

Your image would fade in time ,

But you left memories
Of your laughter in my mind.

You left memories
Of your goodness
On my soul.

Before you came
I was crippled and lame,

Haifa man. and you made me whole.
You left memories
Of you r good ness
On my soul.

You left memories
Of your love
Wherever I go.

I can 't forget

Your love, but yet

Memories are all I'll ever know.

You left memories
Of your love
Wherever I go.

Robert L. Smith, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward M.D., Editor,
West Virginia Medical Journal, P. O. Box 4106, Charleston, WV 25364.

NOVEMBER 1994, VOL. 90 487

o o

Department of Health & Human Resources

Bureau of Public Health News

This page of material is submitted and paid for
by the Bureau of Public Health.

Health commissioner
wins national award

William T. Wallace Jr., M.D.,
the state health commissioner, was
presented the McConnack Award
during the 1994 annual meeting of the
Association of State and Territorial
Health Officials (ASTHO) in St. Louis,
Mo., in recognition of his contributions
to the public health field

Dr. Wallace has more than 30 years
experience in public health, beginning
with his career in the U.S. Public
Health Service, Division of Indian
Health at Hastings Hospital in
Tahlequah, Okla. He spent nearly 10
years in the African republic of Liberia,
first performing missionary work and
then serving as a county public health
officer and a director of medical
services with the republic’s Ministry of
Health and Social Welfare. Since 1990,
he has served as the public health
commissioner in West Virginia, and
prior to this, he held the position of
director of public health in New
Hampshire for 10 years.

Dr. Wallace’s nomination for the
award cited his dedication to public
health, his strong leadership skills and
support for his staff, and his belief in
“people before programs.”

WVPHA honors two
officials, tobacco
control coalition

Public health professionals Dr.
James H. Walker and John Cooper,
R.S., and the West Virginia Tobacco
Control Coalition were among the
honorees during the 70th annual
meeting of the West Virginia Public
Health Association.

Dr. Walker, of Charleston, was
inducted into the WVPHA’s Hall of
Fame for his dedication to public
health for more than 40 years. He
currently serves as medical director for

the West Virginia Bureau of Public
Health’s Handicapped Children’s
Program and Tuberculosis Control
Program. Dr. Walker began his career
as a leader in cardiac research and care,
perfonning the first open heart surgery
in the state in I960. His work with
handicapped children and tuberculosis
patients has brought great insights and
innovations to both fields.

Cooper, local administrator of the
Jefferson County Health Department,
received the WVPHA’s Public Health
Merit Award. He began his career 40
years ago with the Tri-County Health
Department serving Jefferson, Berkeley
and Morgan counties and he has
received numerous awards over the
years for his contributions as a public
health sanitarian.

The West Virginia Tobacco Control
Coalition received the Public Health
Merit Organization Award, as well as
the Health Education and Training
Section Award for Health Promotion.
The WVTCC was formed in 1988 and
currently has more than 50 members
statewide, dedicated to promoting
healthier lives by reducing tobacco
use and its consequences, including
secondhand smoke.

Over the past two years, the
WVTCC was helpful in working with
boards of health to get clean indoor
air regulations passed in 10 counties.
The coalition supports legislation for
state and local clean indoor air laws
and for laws to prevent youth access
to tobacco.

New law requires
insurance coverage
of immunizations

West Virginia physicians need to be
aware that a new state law mandates
insurance companies operating in the
state to pay for all immunization
services for children age 16 and
younger.

Effective July 1, House Bill 4516
requires that insurance policies
provide for the costs of vaccine and
vaccine administration if these
expenses are incurred by the health
care provider. All health insurance
policies are required to pay for these

services whether or not the policy
holder’s deductible has been met.

In addition, under the new law
health care providers are required to
provide parents of newborns and
preschool-age children with details
about diphtheria, polio, mumps,
measles, rubella, tetanus, hepatitis b,
haemophilus influenza b and
pertussis (whooping cough) and free
immunization services for children.

For more information about the
new law or about immunization
services in West Virginia, call the
Bureau’s Immunization Program at
(304) 558-2188 or 1-800-642-3634.

Satellite course on
immunization to be
offered this winter

The National Immunization Program
is offering the first live, interactive
satellite teleconference course in
conjunction with the U.S. Centers for
Disease Control and Prevention, the
University of North Carolina at Chapel
Hill and the North Carolina State
Health Department.

The course will consist of four
3-hour modules concentrating on the
epidemiology of vaccine-preventable
diseases and practical information on
the use of vaccines. The modules are
scheduled for January 19, February 2
and 16, and March 2. Each session will
air from noon until approximately 3 or
3:30 p.m.

There is no fee to participate and
the course is open to physicians,
nurses, clinic staff and other health
care providers. A total of 12 CME
(Category I of AMA) or 1.5 CEU credits
will be available.

If you are interested in taking part
in the course or would like more
information, call Savolia Ellis of the
Bureau's Immunization Program at
(304) 558-2188 or 1-800-642-3634. Ms.
Ellis must hear from you as soon as
possible in order to determine the
number and location of the downlink
sites needed, as well as to complete
the course enrollment procedures. In
addition, a registration form appears
in the November 15 issue of the
WVSMA's newsletter, WESGRAM.

488 THE WEST VIRGINIA MEDICAL JOURNAL

MEDICAL AND SURGICAL SERVICES PROVIDED THROUGH

EYE EAR NOSE and THROAT PHYSICIANS
& SURGEONS OF CHARLESTON, INC.

• 35-bed JCAHO Accredited

Hospital

• Ambulatory Care/

Same Day Surgery

OPHTHALMOLOGISTS
Robert E. O’Connor, MD
Moseley H. Winkler, MD
Samuel A. Strickland, MD
James W. Caudill, MD
R. David Allara, MD

Specializing in
Cataracts/Lens Implants
Corneal Transplants
Ophthalmic Plastic Surgery
Retinal Surgery
Laser Eye Surgery

OTOLARYNGOLOGISTS
Romeo Y. Lim, MD
R. Austin Wallace, MD
Robert E. Pollard, MD

Specializing in
Head and Neck Cancer
Surgery
Ear Surgery
Microsurgery
Endoscopy
Laser Surgery

THE EYE AND EAR CLINIC OF CHARLESTON, INC.

1306 KANAWHA BOULEVARD, EAST
CHARLESTON, WEST VIRGINIA 25328
(304) 343-4371 OR 1-800-642-3049 (WV)

FAX (304) 353-0215

IN MEDICAL SYSTEMS

-14 years experience

-Based in West Virginia

-We support over 450 physicians

-The system is customized for your specialty

-Electronic Media Claims, Electronic Remittance

-Managed Care

Linda Ireland
1420 Kanawha Blvd. West
Charleston, WV 25312
.. r ,n . , 304-346-8312

Medical Systems Inc 800-242.5901

Andy Williams
30 West Sixth Ave.
Huntington, WV 25701
304-522-4361

Formerly Medical and Professional Systems and Turnkey Business Systems

Robert C. Byrd
health Sciences Center

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert P'Vtf* r'pfltPI*

C. Byrd Health Sciences Center of West Virginia y C VjClllCl X CCCIV

University, Communications Division, Morgantown frOITl LiOflS

Omert named trauma
chief, center director

Center on Aging
established at HSC

A Center on Aging
has been created at
the HSC to coordinate
and expand WVU’s
services to the state’s
older citizens.

This new center
will act as a resource
for experts in aging
throughout WVU,
according to W.
Robert Biddington,
D.D.S., associate vice president for
health sciences and interim director of
the new unit. "There are unique unique
challenges and opportunities associated
with aging in rural Appalachia.”

The center will bring together several
efforts, including the 65-Plus Clinic in
the Physician Office Center; educational
programs for undergraduate students
and graduates in the health and social
services professions who work with the
elderly; and research programs focused
on ailments affecting older people. Drs.
Richard Layne, Marilyn Jarvis-Eckert,
and Robert Keefover will serve as the
center's three associate professors.

Major research efforts are being
directed at Alzheimer’s disease and
similar disorders. The opening of the
state-of-the-art Positron Emission
Tomography facility will substantly
enhance research in brain disease, such
as Alzheimer’s dementia.

Charleston Division
names ob/gyn chair

Dr. E. Reed Heywood has been
appointed chair of the Department of
Obstetrics and Gynecology at WVU’s
Charleston Division.

Dr. Heywood is a graduate of the
Utah College of Medicine who has
been a faculty member in academic
medicine for 22 years. He has interests
in infertility surgery and education
administration.

The University Eye Center is
purchasing new computerized vision
testing equipment thanks to a $31,000
grant from the West Virginia Lions
Sight Conservation Foundation. This
equipment will be part of the newly
named West Virginia Lions Visual
Function Laboratory, which will
provide comprehensive testing for the
diagnosis and treatment of eye disease.

A full range of electrophysical tests
useful for diagnosing and managing
many common eye disorders, such as
glaucoma and diabetic retinopathy,
can be conducted with this new
equipment. Other tests available can
help diagnose inherited eye disease in
young children, indicating whether the
disease is stable or progressive, and
alerting families that other family
members may have the same disease.

In addition, patients with cataracts can
get an accurate prediction of how well
they will be able to see after surgery.

A previous donation from the Lions
in 1991 funded the construction of
the Lions Clinical Research Unit,
which houses the new laboratory.

Bone marrow project
celebrates 2nd year

The Bone Marrow Transplant
Program at the Mary Babb Randolph
Cancer Center celebrated its second
anniversary on October 14.

Since the clinic was opened on
October 14, 1992, 116 bone marrow
transplants have been performed at
the center, which is the only facility
in West Virginia for these procedures.

Visiting Physicians
Program created

The Department of Family Medicine,
in conjunction with the Department of
Medicine, has implemented a Visiting
Physicians Program.

This program gives selected internists
and family practitioners the opportunity
to visit the 1 ISC and spend a half a day in
a learning rotation.

Dr. Laurel Omert,
assistant professor
of surgery, has been
appointed chief of
the Section of
Trauma in the
Department of
Surgery and director
of the Jon Michael
Moore Trauma
Center.

Dr. Omert has
been serving in these two positions in
an interim capacity since January.

CAMC Foundation
assisting MDTV

The Charleston Area Medical Center
Foundation has awarded a $498,000
grant to support Mountaineer Doctor
Television (MDTV).

The grant, directed to CAMCs
Continuing Education unit, will enable
CAMC to purchase the equipment to
connect three sites in Charleston to the
MDTV system. Health care professionals
at each of the sites will have full
communications capability with all of
the hospitals on the MDTV network.

Toffle appointed
ob/gyn vice chair

Dr. Roger Toffle, associate professor,
has been named vice chair of the
Department of Obstetrics and
Gynecology.

Dr. Toffle is also director of the
Department of Obstetrics and
Gynecology's Reproductive
Endocrinlogy/Fertility Division.

Brancazio receives
best ob paper award

Dr. Leo Brancazio, assistant professor
of obstetrics and gynecology, received
the award for the best paper at a recent
meeting of the Society of Obstetric
Medicine.

Biddington

Omert

490 THE WEST VIRGINIA MEDICAL JOURNAL

THE WHEELING CLINIC

WHEELING, WEST VIRGINIA 26003

Wheeling. 234-2000 • St. Clairsville, (614) 695-2511 • New Martinsville area, 455-2222 • Wellsburg-Steubenville area, 737-3700

INTERNAL MEDICINE
General

P. Heyat, M. D. (St. Clairsville)
P. R. Hedges, M. D.

G. Ortiz, M. D. (St. Clairsville)

Peripheral Vascular Disease

J. D. Holloway, M. D.

Cardiovascular

A. M. Valentine, M. D.

W. E. Noble, M. D.

Kris Reddy, M. D.

J. Dalai, M. D.

A. E. Frenn, M. D.

Rheumatology

R. Vawter, M. D.

GENERAL SURGERY

E. C. Voss, M. D.
G. Galvin, M. D.

OPHTHALMOLOGY

R. V. Pangilinan, M. D.

D. Simbra, M. D.

H. F. Leeper, M. D., Ph.D.

D. B. Christie, M. D.

Kathryn M. Clark, O. D.

OTOLARYNGOLOGY/

MAXILLO FACIAL SURGERY

W. A. Tiu, M. D.

A. G. Matadar, M. D.

RADIOLOGY

Valley Radiologists, Inc.

FAMILY PRACTICE

E. L. Coffield, M. D. (New Martinsville)
C. P. Entress, M. D.

T. H. Korthals, M. D. (St. Clairsville)

J. H. Mahan, M. D. (St. Clairsville)

PODIATRY

B. Blank, D.P.M. (St. Clairsville)

DERMATOLOGY

G. A. Ganzer, M. D.

NEUROLOGY

H. L. Kettler, M. D.

ANCILLARY SERVICES
Optical

Speech Therapy/Audiology

Dietetic Counseling

Electrology/Cosmetic Therapy

Electrocardiography

Electroencephalography

Neurological Studies (Non-invasive)

Roentgenology

24° A/EEG Scanning Service

Cardiac Ultrasound

Clinical Laboratory

Wrest Virginia is ranked third in the nation for smoking and first in the

nation for smokeless tobacco use. The West Virginia Tobacco Control
Coalition supports three statewide policy measures to reduce tobacco use
and its effects. Help improve the health of West Virginians by advocating for these
pieces of legislation:

Statewide Clean Indoor Air would restrict smoking in designated
public places and work sites. Protects nonsmoking citizens and
provides a supportive environment for those who want to quit.

Youth Access Prevention would require retailers to be licensed to
sell tobacco products to hold them more accountable to current law
that prohibits sales to people under 18. Prohibits free sampling or
coupon distribution and requires lock-out devices for vending machines

Tobacco Excise Tax would increase the excise tax on cigarettes and
impose the first tax on smokeless tobacco. Studies show that as the
price increases, smoking rates decline - especially among youth.

The West Virginia Tobacco Control Coalition is made up of 50 member organizations, including
the American Lung Association of West Virginia, the American Cancer Society, West Virginia
Division, Inc. and the American Heart Association of West Virginia.

Marshall University
School of Medicine

MARSHALIMJNIVERSITY

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

Med School to send medical team to Venezuela

They may live a primitive lifestyle, but the Yanomami
Indians in southeastern Venezuela desperately need
modern medicine to combat the diseases that are attacking
them.

Next month the Marshall University School of Medicine
will come to their aid.

Dr. John Walden will lead an emergency medical team on
the first of a three-phase program to help the Yanomami
help themselves.

“These are, by far, the least acculturated tribesmen in the
world,” said Walden, who is a tropical medical specialist,
associate dean and chief architect of the plan.

Malaria, hepatitis B, river blindness and, most recently,
tuberculosis are plaguing the Yanomami, a 15,000-member
tribe living along the Orinoco River.

Walden plans first to scout out the geography for
potential airstrips and to bring a few vaccines. In January, a
larger team will bring more medicines. In the third phase,
he and others will train the indigenous people in the ways
of modern medicine so they can return to their remote
villages to treat others.

“Most have no access to health care,” Walden said. “And
they have no way of defending themselves without modern
medicine.”

Walden, a veteran of 70 trips into the jungle, has
orchestrated a multifaceted project. He is working with the
Amazonia Foundation, the Healthcare Foundation of the
United Kingdom and Virgin Atlantic Airways.

The last has been raising money for his efforts and its
chairman plans to accompany Walden on the January trip.

Walden also is working with several Venezuelan
organizations, including a group of physician providers.

“It’s the pleasure of my life,” Walden said about his nearly
three decades of working in remote areas of Central and
South America.

“I like the jungle and the Indians. I take pleasure in their
company.”

Walden, 51, must totally rely on their survival skills
when he travels there. He speaks some of their ancient
language but most often uses his Spanish and Portuguese
with native guides.

The patriarchal Yanomami hunt with bows, arrows, spears
and clubs and raise some food by farming. They wear only
loincloths and they sleep in hammocks in large, circular
buildings called shabanos.

“The Indians are remarkable,” Walden said. “They have
managed to remain so isolated.”

But why involve medical students in so remote a culture?

For many reasons, Walden said.

Physicians need to be sensitive to cross-cultural concepts,
he said.

This is one of the many Indian families Dr. John Walden has cared for
during his trips to Central and South America over the past 25 years. Dr.
Walden says working in Third World regions gives medical students and
physicians new perspectives on health and sickness, life and death.

“As they learn about cost-containment, what better way
to appreciate it than in a situation where you literally have
to watch every penny,” he said.

Walden said such experiences also help students learn
when to prolong life and when not to.

“There comes a time for all of us to let go,” he said.

“You find yourself able to do that in a better fashion when
we have these experiences overseas.”

The Yanomami, perhaps the most remote and
unacculturated tribe left on earth, are another step for
Marshall medical students.

Already, Walden said, the school has sent students to 23
countries across the globe.

“After one trip, they feel energized," Walden said.
“They're ready to go back into what they are training for.”

(Reprinted with permission from the Charleston Daily Mail)

492 THE WEST VIRGINIA MEDICAL JOURNAL

A Dollar A Day

will help things go your way!

$365 Club

WESPAC
P.O.Box 4106
Charleston, WV 25364

High blood pressure is trouble waiting to
happen. For more information about the dangers
of high blood pressure call 1 -800-AHA-USA1 .

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Med Student
Section

Several changes proposed for MSS bylaws

Editor’s Note: Vie following sections in bold type are the proposed changes to the bylaws for the WVSMA 's
Medical Student Section. In accordance with the MSS ’s Constitution and Bylaws, any proposed
amendments must he published in the West Virginia Medical Journal 30 days in advance of the
MSS's Annual Business Meeting. Viis year's meeting will take place on Saturday, January 21 at
the Radisson Hotel in Huntington during the WVSMA 's Mid-Winter Clinical Conference. If you
have any questions about these proposed changes, contact WVSMA Membership Coordinator
Donna Webb at (304) 925-0342

CHAPTER II OFFICERS

Section 1. The officers shall be President, Vice President, and Secretary/Treasurer who shall serve one year
terms. Nominations for officers will be accepted from any active member of the Section at the Annual MSS
meeting to be held in the month of January. “A nominee may be any active member from a component
student medical society. A curriculum vitae and personal statement are required to be provided by a
nominee at the time of the nominations.” Nominations may be made in the form of either voice
nomination during the business meeting or as a letter of nomination signed by two active members
accompanying the nominee’s curriculum vitae and personal statement. Personal statements may be
made in writing or by speech during the Annual Meeting. Within two weeks following the Annual
Meeting a ballot will be mailed to all active members. Each member will then have 14 days to return
their ballot to the WVSMA office. Ballots will be signed to validate the member’s status. The Executive
Council and/or an appointed Election Committee will then meet to tally the votes.” In the event of a
tie, the President shall cast the deciding vote. If so elected, a Councilor must relinquish his/her seat as
Councilor.

CHAPTER III. DELEGATES

Section 1. The President during his or her term of office shall serve as the Delegate to the WVSMA Annual
Meeting. The Vice President shall serve during his or her term of office as the Alternate Delegate to the
WVSMA Annual Meeting. The President may appoint the Secretary/Treasurer to serve as the Alternate Delegate
to the WVSMA Annual Meeting if the Vice President is unable to serve. If the Vice President or the
Secretary/Treasurer is unable to serve as Alternate Delegate, the President may appoint a Councilor.
“Likewise, if the President is unable to serve as Delegate, then the Vice President shall serve as the
Delegate and Alternate Delegate shall be the Secretary /Treasurer.”

Section 2. “The delegates to the AMA National Meeting shall be the President of the Executive Council
who shall represent his or her component society, the Vice President of the Executive Council who
shall represent his or her component society, the Secretary /Treasurer of the Executive Council who
shall represent his or her component society. In the event that the Vice President and the President
are from the same component society, the Vice President shall serve as the Alternate Delegate from
his or her component society. In the event that the Secretary /Treasurer is from the same component
society as the President or Vice President, the Secretary/Treasurer shall serve as the Alternate
Delegate from his or her component society. In the event that all three officers of the Executive
Council are from the same component society, the President shall serve as the Delegate from the
component society and the Vice President shall serve as the Alternate Delegate from the component
society.”

494 THE WEST VIRGINIA MEDICAL JOURNAL

Section 3 ■ “Each component society shall have at least two representatives. If a component society is
represented by only one member within the Executive Council, the Alternate Delegate shall be the
President of the Component Society. If the component society is represented by two members
within the Executive Council, the representative positions will have been fulfilled and said
component society shall not chose any further Delegates or Alternate Delegates. If a component
society is not represented within the Executive Council, the Delegate shall be the President of the
component society and the Alternate Delegate shall be the Vice President of the component society.”

Section 4. “If the Delegate or Alternate Delegate, as determined by the preceding sections is unable to
fulfill his or her duties, the Executive Council shall appoint a representative from the same
component society of said Delegate or Alternate Delegate to fulfill the term of the Delegate or
Alternate Delegate who is unable to fulfill his or her duties.”

New Members

We would like to welcome the
following new members to the
WVSMA:

Physicians

David G. Chaffin, MD
830 Pennsylvania Avenue
Charleston, WV 25302

David E. Hess, MD
109 Doctor’s Drive
Bridgeport, WV 26301

Jack Traylor, MD
2561 3rd Avenue
Huntington, WV 25701

Andrew Berens, MD

RR 2, Box 78D

Berkeley Springs, WV 25411

Murshid A. Latif, MD
Rt. 4, Box 9A
Physician’s Building I
Weston, WV 2645 2

Omayma T. Touma, MD
191 Camelot Drive
Huntington, WV 25701

Juan M. Limjoco, MD
2900 First Avenue
Huntington, WV 25702

M.A. Ghannam, MD
601 Chestnut Street
Charleston, WV 25309

Amando Medina, MD
918 Chestnut Ridge Road
Morgantown, WV 26505

Imran T. Khawaja, MD
1801 6th Avenue
Huntington, WV 25702

Resident Physicians

Walid H. Azzo, MD
Bluefield, WV

Ginamarie Foglia, MD
Morgantown, WV

Joohyong Kim, MD
Morgantown, WV

We would like to thank the following
physicians and Alliance members for
their contributions to WESPAC:

Physicians

A Dollar A Day Club

* Designates more than $365 in
contributions

Harrison

Carlos A. Naranjo

Sustainer Members

Cabell

David Weinsweig

Central

Luis Almase
N.B. Ranade
John Echols

Eastern Panhandle

Colin Iosso
Vigilio Tan

Kanawha

Gorli Harish

Extra Miler Members

Parkersburg Academy

John Beane

Kwangsup Sheen, MD
Wheeling, WV

Kimberly Burgess, MD
Huntington, WV

Salam Rajjoub, MD
Wheeling, WV

Mohanted I. Badr, MD
Wheeling, WV

Medical Students

Regular Members - $25
Gold Members - $26 to $150

Regular Members

David Faber
Frank W. Alderman
Mary Keyser
Melissa Matulis
Terry Waxman

Residents

Gold Members

Kurt Palazzo
David Hess

Alliance Members

Regular Members

Greenbrier

Ramah Jones

Sustainer Members

Central

Anne Ramirez

Harrison

Sue Bryant

WESPAC Members

NOVEMBER 1994, VOL. 90 495

Obituary

Robert W. Coplin, M.D.

Dr. Robert W. Coplin, 81, of
Ellizabeth, died September 30 at the
Coronary Care Unit of Camden-Clark
Memorial Hospital after a brief illness.

Dr. Coplin was born in Zacksville,
W.Va., and attended Wirt County
schools and Morris Harvey College in
Charleston. He received a bachelor of
science degree in 1935 from West
Virginia University, and his M.D.
degree from the University of
Louisville, where he specialized in
gynecology and surgery.

After an internship at St. Marys
Hospital in Huntington, Dr. Coplin
established a practice at the Rowley
Clinic in Huntington. He returned to
Wirt County in 1947 to take over his
father’s practice and he built the
Coplin Clinic in Elizabeth. His private
practice continued after the hospital
division of the Coplin Clinic closed in
I960. Under his leadership, the clinic
became the Coplin Memorial
Community Health Center, where he
served as senior medical advisor.

Dr. Coplin was also instrumental in
building Roane General Hospital in
Spencer, where he served on the
medical staff.

During his career, Dr. Coplin served
for many years as the Wirt County
Health Officer and continued
conducting clinics for the Health
Department even after he retired in
1981. He served as medical director
for the Wirt County Emergency
Services and often instructed classes
for emergency medical technicians.

He was the first medical examiner of
Wirt County and helped coordinate
the county’s first bloodmobile.

Active in the Wirt County schools
and in the Elizabeth communty, Dr.
Coplin conducted free sports clinics
and served as team physician for
many years. He was also honored for
his years of service as team physician
for the Wirt County Pee Wee/Pop
Warner football program. In addition,
he served more than eight years on
the Elizabeth Town Council and was
on the board of directors of the Wirt
County Bank.

In 1991, Dr. Coplin was the first
member of the WVSMA to receive the
WVSMA’s Rural Physician Award for
his years of dedication to rural health
care. He was also the recipient of the
Community Service Award by the
Church of the Nazarene in 1988, and
he was honored by Camden-Clark

Memorial Hospital in 1985 for 36
years of outstanding medical service.

A commissioned officer in the U.S.
Army medical corps during World
War II, Dr. Coplin served in both the
European and Pacific theaters and
Panama. In addition to being a
member of the WVSMA, Dr. Coplin
was also a member of the AMA; the
Elizabeth Baptist Church; the
Elizabeth Lions Club; the Cabell Lodge
152, AF & AM; Scottish Rite of
Charleston; Huntington Chapter 6,
RAM; Beni Kedem Temple of the
Shrine; BPOE 198 of Parkersburg; and
an admiral of the Cherry River Navy.

Surviving are his two sons, Richard
Coplin of Elizabeth and Jay Coplin of
Charleston; his daughter, Dinah Law
of Wheeling; and a grandson. He was
preceded in death by his wife, Mildred
“Mim” Pettit Coplin; and two brothers,
Rolla W. Coplin and Harry W. Coplin.

Memorials are preferred to County
Senior Citizens, Elizabeth Baptist
Church, or the Wirt County High
School Athletic Boosters.

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496 THE WEST VIRGINIA MEDICAL JOURNAL

West Virginia Medical

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

West Virginia State Medical Association

CURNAL -

zrM

Volume 90 No. 12

UNIVERSITY OF MARYLAND

Hi TH. SCIENCES LIB.- ACO

HI SOUTH GREENE STREET
BALTIMORE MD 21201

DEPT

{December 1994

FERRELL P H 0 T Q G R A P H I C S

Specializing in public relations and advertising
photography for the health care industry

1116 Smith Street Suite 217 Charleston, WV 25301 Phone:(304)340-4254

EDITOR

Stephen D. Ward, M.D., Wheeling
(Chairman, Publication Committee)

MANAGING EDITOR

Nancy L. Hill, Charleston

EXECUTIVE DIRECTOR

George Rider, Charleston

RESIDENT EDITOR
Linn M. Mangano, M.D., Morgantown

ADVERTISING DIRECTOR
Michelle Ellison, Charleston

Published monthly by the West Virginia
State Medical Association under the direction
of the Publication Committee, Original
articles are accepted on the condition that
they are contributed solely to the West
Virginia Medical Journal.

Postmaster send form 3579 to the West
Virginia Medical Journal. 4307 MacCorkle
Avenue, S.E., Charleston, WV 25304.

Entered as second-class matter January 1,
1926, at the post office at Charleston, West
Virginia, under the act of March 3, 1879.

WEST VIRGINIA MEDICAL 1QURNAL

(ISSN 0043-3284) is published monthly by
the West Virginia State Medical Association,
4307 MacCorkle Avenue, S.E., Charleston,
WV 25304.

Subscription Rates: $45 a year in the U.S.;
$80 in foreign countries; $4 per single copy.
Address communications to the West
Virginia Medical Journal, P. O. Box 4106,
Charleston, WV 25364.

Microfilm editions beginning with the 1972
volume are available from University
Microfilms International, 300 N. Zeeb Roaa,
Ann Arbor, MI 48106.

USPS 676 740
ISSN 0043 - 3284

West Virginia Medical

CURNAL

Contents

Feature Article

Dr. Henry M. Hills Jr.: Our own hero of the Battle of the Bulge 506

Scientific Newsfront

The treatment of gastroesophageal reflux disease 510

Manuscript Guidelines 517

Exercise Induced Anaphylaxis: One more cause for syncope 518

President’s Page

Protecting our children 520

Editorial

Battle of the Bulge: A remembrance 521

In My Opinion

Managed care = veterinary care 522

Special Departments

General News 524

Registration Form for the WVSMA/WVACP’s 1995 Mid-Winter

Seminars and Scientific Conferences 527

Continuing Medical Education 528

Medical Meetings/Poetry Corner 529

Bureau for Public Health News 530

Robert C. Byrd Health Sciences Center of WVU News 532

Marshall University School of Medicine News 534

Obituaries 536

Registration Form for the WVSMA Medical Student Section’s

Annual Meeting 537

1994 Index of Scientific Authors 538

1995 Advertising Rates 540

Classified 541

December Advertisers 542

Front Cover

This year’s Christmas tree at the State Capitol in
Charleston creates a festive holiday scene. Photo courtesy
of Robbie Parsons of South Charleston.

DECEMBER 1994, VOL. 90 505

Dr. Henry M. Hills Jr.: Our own
hero of the Battle of the Bulge

At the WVSMA’s Annual Meeting at The Greenbrier in August, Dr. Henry Hills and Dr. Michael
Fidler proudly stand with the exhibit which Dr. Fidler created to honor Dr. Hills and the other
Army doctors and surgical technicians who flew across enemy lines in a glider to care for
soldiers at the Battle of the Bulge. This display won the Southern Medical Association
Auxiliary’s Medical Heritage Award for the Best County Exhibit in its class.

Editor’s Note: Dr. Hills is an
orthopedic surgeon in Charleston
who has been a member of the
WVSMA and the Kanawha County
Medical Society since 1941 . His
heroic actions during World War
II were recently documented in a
special manuscript by Dr.

Michael Fidler, who is also a
Charleston orthopedic surgeon.
Tljis article is compiled from
exerpts in Dr. Fidler’s interview
with Dr. Hills and his wife, Willie.
In conjunction with this article,
an editorial about the Battle of
the Bulge appears on page 521.

In 1941 at the start of WWII, Dr.
Henry M. Hills Jr. had been in practice
in Charleston with orthopedic surgeon
Dr. Randolph Anderson, and he had
gone to Boston for further orthopedic
training at Massachusetts General
Hospital. He and his wife, Willie, a
nurse, had been married for three
years and she was teaching home
nursing courses and working in
Boston at the Joslin Clinic.

Since he had enlisted, it wasn’t long
before Dr. Hills was called to duty and
he was assigned to Walter Reed Army
Hospital in Washington, D.C., for
training. Before he was sent overseas
to the 12th Evac Hospital, Dr. Hills
went on maneuvers in Tennessee and
at a camp near Boston.

It was a tearful day when Dr. Hills
had to leave for England and leave
his beloved Willie, who was pregnant
at the time with their son. Little did
they know it would be three and a
half years before they would see each
other again.

When he arrived in England, Dr.
Hills spent 18 months taking care of
the 8th Air Force in their bombing
runs over France and Germany.

“We worked like hell,” Dr. Hills
remembered. “We had a big clinic.
The most notorious thing was the ‘3B
fracture’ - - Beer, Blackout and
Bicycle - - they all broke their radial
heads. Then, just before the invasion,

we were put in Patton’s army, the 3rd
Army. The first directive we got was “If
you do not take the objective and are
not killed or mortally wounded in the
attempt, you will be court-martialed.”

On D-Day, Dr. Hills and the 3rd
Army were set up in a hospital on
the English coast to receive patients
from the invasion. The 3rd Army was
made up of two tank divisions for
every infantry division. According to
Dr. Hills, “one division would punch
a hole, then the tanks would go up
and down the line and tear the
enemy to pieces. The Germans were
scared to death of General Patton
and they needed to be. We had a
terrible striking force,” he added.

They were at their beachhead for
about two weeks, and during this
time Dr. Hills had his first meeting
with General Patton.

“Patton was a great fellow,” Dr.
Hills commented. “He came into the
clinic to have his nose treated. He
had a cold and stopped up nose, and
the colonels came around and fawned
over him. He turned around and said
‘What’s the matter with these people?

I can’t do anything to help them.”
(Patton was criticizing the colonels for
making over him so much, as well as
referring to the fact that it was a
“typical New York outfit because the
city guys would knife you to get
ahead of you,” Dr. Hills said.)

After leaving the beaches of
Normandy, Dr. Hills and his unit
moved constantly with the front so
they could operate hospitals as
needed. His typical day would consist
of a 12-hour shift in surgery where he
would usually operate on 20-40
patients. Then, he would check on his

506 THE WEST VIRGINIA MEDICAL JOURNAL

patients and go over charts for about
eight hours before grabbing four or
five hours sleep. This cycle soon took
its toll on Dr. Hills.

“There were a lot of severe
wounds such as hip wounds and so
forth," Dr. Hills recalled. “And that’s
when I lost my cool.

“We were in Luxembourg in a
hospital building and I had a
Luxembourger who was to help
around my surgery unit. He didn't
know any English at all, and I didn’t
know his language. At that time I was
working real hard, there would be 20
or 30 lined up whenever I came on
duty. I’d get them done and think,
‘Good, next time I come there won’t
be so many.

“Well, next time there would be 20
or 30 or 40. So, I’d get to the point
where things would happen, like I
would be in a hip and a bleeder
would get loose, and I’d utter a swear
word or twro and I’d clamp the damn
thing. Then, it would come loose
again, so I would clamp it and tie it
again and it would start to come
loose. I’d utter some special words,
and I finally got to where I was even
throwing some instruments, getting
kind of wild. I made up my mind I
wasn’t going to say another word,
wasn't going to do a thing, no matter
what happened.

“Well, I got into a hip again, and a
gluteal vessel came loose. 1 had a hell of
a time with it, but I didn't say anything.
But, I picked up an instrument and I
threw it down, and this Luxembourger
says, “Gott dammit!”

About two weeks later. Dr. Hills
and the 12 Evac Hospital unit went to
Nancy, where they came under attack
from the long German siege guns.

“The Germans shelled our hospital
and a 750 pound shell was buried 20
feet in the ground right below our
unit, right at the corner of our
hospital in the orthopedic ward,” Dr.
Hills said emphatically. “Fortunately,
it didn’t go off. The shells would
come in regular as time. Just as you’d
go off to sleep - - ‘WHEEEEEEEE’ - -
in would come another one. And
then they would move the seige gun
a little further down the railroad track
before anyone could hit it.”

While Dr. Hills was in Nancy, the
Battle of the Bulge began and a
commander asked for volunteers to
parachute in to the front by glider to
care for about 800 casualties in a
garage. He volunteered to go because
he said he was “so mad” that there
were so many patients at the hospital
who were trying to get out of serving.

Dr. Henry Hills and his wife, Willie,
celebrated their 56th wedding anniversary
this year. The Hills are pictured here at The
Greenbrier during the WVSMA’s Annual
Meeting in August.

On Christmas Day, Dr. Hills was
taken to an airstrip with Dr. Edward
Zinschlag and two sergeants who had
also volunteered. They were the first
medical personnel to ever be flown
behind enemy lines, and the pilots in
the gliders had tommy guns. At the
last minute, it was decided that Dr.
Hills and the others would not have
to parachute in because there were so
many supplies that needed to be
taken. So, the gliders were loaded up
and off they flew on the 100-mile trip.

Even though the gliders were shot
at by the Germans and a few bullets
went through one of the cabins, they
had a smooth landing in a field and
no one was injured. As soon as they
landed, a GI with long whiskers came
out and said, “What the hell are you
doing out here? This the outmost
outpost of the 101st Airborne. Get the
hell in here!”

About that time, rockets starting
going off and the group was taken into
a shallow area for protection. Then,
they were taken two at a time in a jeep
as fast as possible so mortars wouldn’t

get them. When they arrived at the
garage, it had only a parachute for a
door, and the minute they pulled it
aside to walk in they were taken aback
by the smell of gas gangrene.

“Here were these creatures, lying on
parachute cloths, no lights,” Dr. Hills
remembered sadly. “Some women
from Bastogne were there trying to
help, giving them water and so forth,
and the men were dying like flies.
They’d been there for 10 days with
wounds that were now gas gangrene.

"The only light was at the far side,
where mechanics did repairs. There
was a field stove with coffee brewing
in that area and they had four tables set
up - - stretchers on sawhorses. They
had a great big vat filled with alcohol.
After a case, we would dump all our
instruments and gloves into the vat. We
had no gowns or masks, of course. For
the next case, you’d reach into the vat
and put your gloves on wet, pick out
the instruments you needed, and go to
work.

“One man in my group acted as a
triage officer. The bottom floor of the
garage had 400 serious casualties. The
top floor had 400 walking casuali1 es
and we didn’t bother with them.

“The first night I was there the triage
officer came to me and said there was
a boy in terrible shape who was not
going to survive until morning. We
had lost all but sLx pints of our blood
when we landed the glider. He said,
Let’s give him a pint of blood and get
his leg off." So, we took him in and
did it. He had a fever of 105 degrees
and was moribund - - didn’t need any
anesthesia; he was out, he was dying.
The next morning one of the nurses
came in and said he wanted to talk to
me. He thanked me; he had made it.”

While Dr. Hills was caring for these
injured men, one of the infantry
colonels got perturbed because he
was amputating limbs. He came down
to see Dr. Hills and said to him, “I
understand your taking them off right
and left here." Dr. Hill replied, “Yep,
those that need to come off.” The
colonel then said, “Well, I'm not quite
sure they do." So, Dr. Hills picked up a
limb and handed it to him. He nearly
passed out and never said a word.

Dr. Hills was on duty continuously
for 50 hours until the U.S. troops were
able to break through with supplies
and ammunition. After this special
mission, Dr. Hills was taken back to
Nancy, where he worked until the end
of the war. He and the other medical
volunteers were awarded the Silver Star
for their heroism and bravery which
saved hundreds of soldiers lives.

DECEMBER 1994, VOL. 90 507

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Scientific Newsfront

The treatment of gastroesophageal reflux disease

BARBARA KAPLAN, PHARM.D.

Assistant Professor of Clinical Pharmacy and
Clinical Assistant Professor of Family
Medicine , Schools of Pharmacy and Medicine,
Robert C Byrd Health Sciences Center of West
Virginia University, Charleston Division
KATHY L, KOPPELO, PHARM.D.

Pharmacist , Ruby Memorial Hospital,
Morgantown

Abstract

Gastroesophageal reflux disease
(GERD) is a common disorder
which may result in esophageal
ulcers, erosions, strictures and
motility disorders if it is not
treated promptly. Physician
assessment of risk factors and
symptoms is essential for accurate
diagnosis and determination of
appropriate treatment. Mild cases
of GERD can be treated with lifestyle
modifications and antacid/ alginic
acid therapy. Moderate and severe
GERD can be treated with
histamine-2-receptor antagonists
(H2RAs) or omeprazole. The
H2RAs require split-dosing, at
least twice daily, and higher than
peptic ulcer disease treatment
doses, while omeprazole 20 to 40
mg may be used. Prokinetic agents
and sucralfate have been used as
adjunctive treatments, however,
conflicting data exist about their
efficacy. Maintenance therapy is
usually required to avoid disease
recurrence; either H2RAs or
omeprazole may be prescribed.

Introduction

Gastroesophageal reflux is a motility
disorder that leads to an increased
dwell time of acid. Many patients
experience this retrograde flow of
stomach or duodenal contents into the
esophagus. In fact, about 36 percent
of the population experiences
heartburn once a month with up to 7
percent having heartburn daily (1).

Gastroesophageal reflux disease
(GERD) is any symptomatic clinical
condition or tissue damage that results
from episodes of reflux (2). GERD is a
common disorder, often treated by the
primary care physician in the

ambulatory setting. For some patients,
GERD is relatively benign and easily
treated, however, others may
experience severe esophageal tissue
damage with potential resultant
esophageal ulcers, erosions, strictures
and motility disorders (2,3). This
article comprehensively reviews the
various treatment modalities for GERD
and provides a rational approach to
therapy selection for physicians.

Pathophysiology

Although the pathophysiology of
GERD is still not totally understood,
the development of GERD can be
mechanical or acid-related.

Gastroesophageal emptying relies
on a functioning lower esophageal
sphincter (LES) to prevent reflux of
gastric contents back into the esophagus.
A pressure gradient exists that favors
reflux into the esophagus since the
stomach has a higher pressure than
the esophagus. However, in normal
patients, the LES exerts a pressure
greater than 12 mmHg over stomach
pressure. LES pressures of less than 12
mmHg may result in reflux; in fact, an
association exists between LES
pressures of less than 5 mmHg and
severe GERD, but this relationship
does not appear to be linear (3).

In normal patients, the LES
spontaneously relaxes to allow food to
enter the stomach upon swallowing.

In GERD patients, the LES
spontaneously relaxes more often and
for longer periods of time, resulting in
lengthened esophageal exposure to
refluxed acid which can lead to
mucosal injury (3,4). The greater the
exposure time, the more likely
irritation or erosion may occur. Causes

of increased esophageal exposure to
acid can include impaired esophageal
peristalsis, hiatal hernia, horizontal
body position, and decreased
salivation (4-7).

In addition to LES abnormalities,
other mechanical and metabolic
causes of GERD exist. For example,
up to 41 percent of patients with
GERD have been shown to have
delayed gastric emptying (8). Delayed
gastric emptying can lead to
distention, increased volume, and
increased intra-abdominal pressure,
resulting in gastric reflux. Another
cause of GERD is hiatal hernias, which
can impair esophageal clearance by
serving as an acid trap that promotes
reflux during relaxation of the LES
induced by swallowing (9). Hiatal
hernias were once thought to be
synonymous with reflux and GERD,
but most hiatal hernias are now
considered to be anatomical variants.

A third factor which may play a role
in the development of GERD is
impaired mucosal defense (4). The
esophageal mucosa is considered to
be less resistant to gastric acid than
other types of large molecules (e.g.,
pepsin) in the GI tract. The primary
irritants found in the refluxate are
gastric acid and pepsin. However,
patients with achlorrhydria can
develop esophagitis which is thought
to be due to bile acids and other
proteolytic enzymes (4).

A final condition that can cause
GERD is a non-functioning pyloric
sphincter because it allows the reflux
of bile acids and proteolytic enzymes
into the stomach and subsequently
into the esophagus, resulting in local
irritation and erosions (3,4).

Table 1: Signs and Symptoms of GERD*

Chest

GI Tract

Throat

Lungs

Misc.

Heartburn
Regurgitation
Dysphagia
Odynophagia
Chest Pain

Bloating
Early satiety
Nausea
Belching

Hypersalivation
Hoarseness
Lump in throat

Aspiration

Asthma

GI blood loss
Hiccups

’Adapted with pe

mission from reference 19

510 THE WEST VIRGINIA MEDICAL JOURNAL

Clinical presentation

Risk factor assessment and a
thorough medical history (including
medication use, symptom description,
related foods, and other disease
states) provide valuable information
for the accurate diagnosis of GERD.
Evaluation is often difficult due to the
signs and symptoms of GERD which
can often be vague and non-specific.

Heartburn is the most common
presenting symptom, and other
symptoms (e.g., chest pain) may be
attributed to other disorders (Table 1).
Some atypical GERD symptoms
include respiratory problems (e.g.,
coughing, hoarseness, and wheezing),
chest pain, and laryngeal or
oropharyngeal symptoms. Dysphagia,
weight loss or unexplained anemia
may indicate severe disease.

Certain medications and foods can
decrease the LES pressure or have a
direct irritant effect, thus causing
reflux symptom. Tables 2 and 3 list
some of the problem foods and
medications that can induce reflux
symptoms and GERD.

Age is another risk factor for GERD.
Infants have decreased gastric
emptying and underdeveloped LES
tone, thus increasing the risk for
reflux. Alternatively, gastric acid
secretion decreases with age. However,
elderly individuals tend to have
decreased salivary production,
esophageal peristalsis, and mucosal
defense factors (10), but they are still
at risk for esophageal irritation and

Table 2. Dietary Factors Which

Contribute to GERD (2,4,11,45)

Alcohol
Caffeine
Chocolate
Fatty meals
Orange juice
Peppermint
Tomato juice

other symptoms of reflux (11). In fact,
one study reported heartburn in 14
percent of elderly ambulatory patients
and abnormal reflux in 20 percent of
this population by ambulatory pH
monitoring (12).

Some other risk factors for GERD
include cigarette smoking, pregnancy,
obesity and scleroderma. Smoking can
cause GERD because the nicotine
decreases LES pressure. Pregnant
women are at increased risk for reflux
since circulating progesterone
decreases LES pressure and the fetus
increases intra-abdominal pressure
(12). Also, about 25 percent of
pregnant women experience
heartburn daily, while 52 percent
experience heartburn monthly (1).
Obesity can also predispose a person
to GERD due to a potential decrease
in LES strength and an increase in
intra-abdominal pressure.

Diagnostic procedures

Besides reviewing a patient's
symptoms, several procedures are
available to help diagnose GERD.

Endoscopy and upper GI series are
used to image the esophagus and upper
GI tract to rule out other diseases (e.g.,
cancer or peptic ulcer disease) and
assess damage to the esophagus.
Another procedure, the Bernstein or
acid perfusion test, has been widely
used since 1958 to determine if atypical
symptoms (chest pain or pulmonary
symptoms) are caused by GERD.
However, due to the occurrence of
false-positive results in patients with
duodenal ulcers or gastritis, patient
subjectivity, and the advent of 24-hour
pH monitoring, the use of the Bernstein
test is severely limited (13).

In addition, 24-hour ambulatory pH
monitoring can detect decreases in
intra-esophageal pH which may also
correspond to patient symptoms of
GERD or reflux, and esophageal
manometry may be performed to assess
esophageal peristalsis before resorting
to surgery (3,4,14).

Table 3. Medications Which Contribute to GERD (2,4,11,45)

Anticholinergics

Narcotics

Antiparkinson agents

Nicotine

Caffeine

Nitrates

Calcium channel blockers

Phentolamine (Regitine®)

Diazepam (Valium®)

Progesterones

Dopamine (Intropin®)

Prostaglandins El, E2, A2

Estrogens

Theophylline (various)

Isoproterenol (various)

Tricyclic antidepressants

Management

Therapeutic goals in the
management of GERD are designed to
relieve patient pain and symptoms, to
decrease frequency and duration of
reflux, to heal mucosal injury, and to
prevent complications and recurrence.
Treatment of GERD is usually divided
into three phases of therapy.

Phase I therapy usually incorporates
lifestyle changes and antacid/alginic
acid therapy (9,10,15,l6)(Table 4).

This therapy helps alleviate symptoms
in most patients with very mild GERD,
however, neither antacid nor alginic
acid therapy promote healing.

If no symptomatic improvement
occurs within two to three weeks or if
the patient is severely afflicted, Phase
II therapy, which consists of
pharmacological measures (Table 5),
should be initiated. Medications are
used for prevention, as well as for
treatment of gastric reflux to lower the
irritating and erosive factors in the
refluxate. Patients with significant
GERD should start with both Phase I
and II therapies. Phase III therapy is
surgery, and it is indicated in about 5
to 10 percent of GERD patients (5,9).

Antacid therapy

Antacids neutralize the gastric acid
secreted by the parietal cells in the
stomach. By increasing gastric pH,
antacids inhibit the proteolytic actions
of pepsin. In addition, antacids bind
to bile salts (17), and may also exert a
cytoprotective effect through
increased prostaglandin release,
increased mucus production and
increased local blood supply (17-20).

There are several types of antacids
including sodium bicarbonate,
magnesium salts, aluminum salts, and
calcium carbonate. Although liquid
and chewable tablet formulations are
the two most commonly used types,

Table 4: Phase I Therapy for GERD (2,4,16)

Lose weight (if over ideal body weight)
Decrease or avoid certain foods (coffee, citrus,
chocolate)

Decrease or stop smoking
Avoid alcohol
Eat smaller meals

Stay upright for 2 hours after meals
Do not eat for 3 hours before sleeping
Elevate head of bed

Avoid tight clothing over abdominal area
Try lozenges to increase saliva production
Antacid/alginic acid therapy

DECEMBER 1994, VOL. 90 511

Table 5: Pharmacologic Measures for GERD Treatment (15,27,28)

Brand

Initial Daily

Mechanism of

Generic Name

Name

Dose*

Action#

Cost uo

Antacids

Various

As needed

1 Gastric acidity

7.46/360ml

(3.50/360ml)

Alginic acid

Gaviscon

As needed

t Esophageal
mucosal protection

5.82/360ml

(4.73/360ml)

Cimetidine

Tagamet

800 mg

J Gastric acidity

72.15

Ranitidine

Zantac

300 mg

4 Gastric acidity

82.16

Famotidine

Pepcid

40 mg

4 Gastric acidity

79.80

Nizatidine

Axid

300 mg

4 Gastric acidity

80.56

Omeprazole

Prilosec

20 mg

4 Gastric acidity

106.75

Sucralfate

Carafate

4 gm**

t Esophageal
mucosal protection

78.00

Metoclopramide

Reglan

20 mg

t LES## pressure,
| gastric emptying

64.01 (13.20)

Bethanechol

Urecholine

50 mg**

T Esophageal
clearance
t LES pressure

38.70

(2.10)

Cisapride

Propulsid

40 mg

t LES pressure;
t peristalsis

72.00

’Higher doses may be warranted if patient fails initial doses
* t = increase, t = decrease

p Cost listed is the average wholesale price for a 30-day supply. Costs are taken from the 1993
Redbook(46) using package sizes of 100 for highest strength product, unless otherwise noted.

0 Generic prices, where available, in parenthesis; prices calculated using the average of three
products.

**Not FDA approved for GERD
##LES = Lower esophageal sphincter

Table 6: Possible Side Effects of Antacid Therapy (2,16,22,28)

Antacid Salt

Trade Name
(Tablets)

Acid Neutralizing
Capacity*

Potential Adverse Effects

Sodium

Bicarbonate

Various

NAp

Sodium overload, systemic
alkalosis, milk-alkali
syndrome

Magnesium

Maalox

Diarrhea, hypermagnesemia,
magnesium cardiotoxicity

Aluminum

Amphogel#

Constipation, systemic
aluminum toxicity,
hypophosphatemia

Calcium

Carbonate

Turns E-X (Extra Strength)

Constipation, hypercalcemia,
acid rebound

* Acid neutralizing capacity per tablet, capsule or 5 ml of suspension is defined as the mEq of HC1
required to keep the antacid suspension at pH = 3.0 for 2 hours.

# Liquid dosage formulation

p Acid neutralizing capacity not available for this formulation

antacids are also available as oral
tablets, chewing gum, powder, and
lozenges. The various antacid salts,
their acid neutralizing capacities and
some possible side effects are listed in
Table 6.

Sodium bicarbonate is usually not
recommended for long-term use

because of its high sodium content
and its ability to cause systemic
alkalosis. Magnesium-aluminum
antacid combinations are most
commonly used since they minimize
or counteract the diarrheal and
constipating effects of the magnesium
and aluminum salts, respectively.

Several different mechanisms for
drug interactions with antacids exist
(Table 7). First of all, antacids can
bind to other drugs, rendering the
bound drug insoluble. Antacids can
also change the gastric pH which can
alter the rate or extent of absorption,
as well as increase urinary pH, which
affect the rate of urinary excretion of
drugs that are weak acids. To avoid
interactions, especially when drugs
with narrow therapeutic indexes are
prescribed, patients should be
instructed to take the medication two
hours before the antacid to achieve
complete absorption (21).

The cost of antacid therapy
depends on the antacid salt, the
dosage form and the frequency of
administration. Liquid antacids are the
most cost efficient formulation due to
their higher acid-neutralizing power
per unit. However, all antacids must
be administered frequently because of
their short duration of action (45 to 60
minutes in fasting individuals). This
duration increases to approximately
two to three hours if the antacid is
taken one hour after meals (16).

Antacids can provide symptomatic
relief, but have not been shown to
promote healing of damaged tissue in
GERD patients (20). In addition, third-
party insurance programs that cover
the cost of prescription drugs, often
do not pay for over-the-counter (OTC)
drugs such as antacids. Due to these
two factors, antacids are best used for
symptomatic relief in patients with
mild to moderate GERD, as adjuncts
to more potent medications.

Alginic acid therapy

Alginic acid, (Gavison®) like
antacid therapy, is best used for
symptomatic relief. Alginic acid is not
an antacid; however, alginic acid
preparations usually contain small
quantities of antacid to convert alginic
acid to sodium alginate, a viscous
foam that floats on the surface of the
gastric contents. If reflux occurs, the
sodium alginate provides a barrier
preventing acid exposure to
esophageal mucosa. Thus, the amount
of antacid in alginic acid preparations
is not sufficient to alter gastric pH
(16).

Alginic acid preparations are
considered to be at least as effective
as antacids for relieving symptoms,
however, like antacids, alginic acid
preparations do not promote healing
in GERD patients (16,22).

5 1 2 THE WEST VIRGINIA MEDICAL JOURNAL

MMS

Histamine- 2-Receptor
Antagonists (H2RAs)

Cimetidine (Tagamet®), ranitidine
(Zantac®), famotidine (Pepcid®), and
nizatidine (Axid®) are the four H2RAs
currently available in the United
States. H2 receptor antagonists inhibit
binding of histamine to H2 receptors
in the parietal cells of the stomach,
resulting in decreased gastric acid
secretion.

Bioavailability ranges from 30
percent with cimetidine to 75 to 100
percent with nizatidine (23). For all
four agents, serum protein binding is
relatively low; e.g., 15% to 20% for
cimetidine, ranitidine, and famotidine,

and up to 35% for nizatidine. Their
elimination half-lives can range from 1
to 4 hours (23). Advanced age and
liver impairment lower cimetidine
clearance, but appear to have little
effect on the other H2RAs. Since all
four drugs are renally excreted,
dosage reductions are recommended
in patients with renal impairment.

Overall, the H2RAs cause few
serious adverse effects. The most
common adverse effects, though, are
diarrhea, headache, drowsiness,
fatigue, muscle pain and constipation,
all of which are reported in less than
3 percent of patients (27).

Due to its structure, cimetidine has
a greater ability to cross the blood

brain barrier which may increase the
likelihood of CNS-related effects,
especially in elderly patients.

Although cimetidine and ranitidine
can increase serum prolactin levels
which may result in breast swelling
and galactorrhea in females and
gynecomastia in males, famotidine
and nizatidine do not. Impotence has
been implicated with cimetidine
therapy; but this condition usually
reverses within one month after
switching to ranitidine (23). Cimetidine
has also caused loss of libido. Finally,
while elevations in serum levels of the
aminotransferase enzymes are usually
reversible, hepatitis has rarely
occurred (23,24).

The H2RAs can increase gastric pH,
thus decreasing the absorption of
drugs dependent upon an acidic
environment, e.g., ketoconazole
(Table 7). Other drug interactions with
the H2RAs are due to their inhibition
of cytochrome P-450 enzymes which
are involved in the hepatic metabolism
of some drugs. While cimetidine is the
most potent inhibitor of cytochrome
P-450, ranitidine binds five to 10 times
less, and famotidine and nizatidine do
not bind significantly (23). Through
competition, H2RAs may also inhibit
renal tubular secretion of certain drugs.

Dosing of the H2RAs for GERD
depends upon the individual and the
severity of the disease. Generally,
clinicians initiate GERD therapy with
standard duodenal ulcer treatment
doses, but in most cases, much higher
doses of H2RAs are required to treat
and manage GERD symptoms. Studies
show that H2RA therapy relieves reflux
symptoms in about 75% of patients;
however, healing may be inadequate
using standard doses since only about
33% of patients are healed (4).

For example, patients given
ranitidine 150 mg twice a day for
erosive or ulcerative esophagitis
showed healing rates after four and
eight weeks of 31% and 50%,
respectively (25). Healing was defined
as macroscopically complete
epithelialization of all erosive or
ulcerative lesions of the esophagus.
Comparing nizatidine 300 mg twice a
day, 300 mg at bedtime, and placebo
showed six-week healing rates of
40%, 30%, and 26 %, respectively (23).

Since approximately 50 percent of
GERD patients fail H2RA therapy,
even at twice the standard dose for
duodenal ulcer (16), many studies
have evaluated high dose or high
frequency H2RA therapy. In one study
comparing ranitidine 300 mg four
times a day with ranitidine 150 mg

Table 7: Selected Clinically Significant Drug Interactions of GERD medications
(16,21,23,26,28)

GERD Medication

Object Drug

Proposed Mechanism*

Antacids

fluoroquinolones

decreased bioavailability of object

tetracycline

isoniazid

iron preparations

drug through binding

H-2-receptor

itraconazole

decreased bioavailability of object

antagonists

ketoconazole

enoxacin

drug due to increased pH of stomach

warfarin

possible increase of object drug

phenytoin

concentrations due to hepatic

theophylline

metabolism

procainamide

increased concentrations of object

triamterene

drugs through inhibition of renal
tubule secretion

Omeprazole

diazepam

increased concentrations and

phenytoin

decreased clearance of object drugs

warfarin

due to inhibition of P-450 enzyme
system

ketoconazole

decreased absorption of object drugs

itraconazole
iron preparations

due to increased pH

Sucralfate

digoxin

possible decreased concentration of

warfarin

phenytoin

theophylline

object drug due to chelation/binding

aluminum-

possible increased aluminum serum

containing antacids

levels

Bethanechol

cholinergic drugs

additive effects

quinidine

procainamide

decreased effects of bethanechol

ganglionic blocking
agents

decreased blood pressure

Metoclopramide

anticholinergic

decreased metoclopramide effects

drugs

opiates

due to decreased GI motility

antihypertensives

alcohol

CNS depressants

increased CNS depression

digoxin

decreased absorption of object

cimetidine

drugs due to increased GI motility

Cisapride

Anticoagulants

possible increased coagulation
times, adjust dose accordingly

* Abbreviations: GERD = gastroesophageal reflux disease; GI = gastrointestinal; CNS = central
nervous system

DECEMBER 1994, VOL. 90 513

twice a day, complete healing of
esophageal ulcers or erosions
occurred in 63% and 75% of the
“high-dose” patients after four and
eight weeks, while 29% and 54% of
the “standard-dose” patients were
healed (15,23). In addition, some
patients have required up to 3,600 mg
of ranitidine per day to promote
healing (26).

While H2RAs are generally
considered to be safe and well
tolerated, studies to determine their
safety at high doses have not been
done, therefore, the lowest effective
dose should always be used. In
addition to higher doses, H2RA
therapy for GERD needs to be given
at least twice a day or more. Split-
dose therapy will inhibit both daytime
and nocturnal acid secretion which
will relieve symptoms, promote
healing, and improve overall outcome
for the patient (27). Unlike patients
with duodenal or gastric ulcers, GERD
patients frequently require prolonged,
treatment doses of H2RA therapy (2).

Omeprazole

Omeprazole (Prilosec®) is a
substituted benzimidazole that
suppresses gastric acid secretion by
irreversibly and non-competitively
inhibiting the acid proton pump of the
parietal cell. Acid suppression is
profound and a single dose will
suppress acid by more than 90% for
24 hours (15). Maximal antisecretory
activity and plasma levels occur about
two hours after an oral dose.

Omeprazole has a high first-pass-
effect; bioavailability is only about
30%-40% of an oral dose and protein
binding is high, about 95 percent (28).
Almost 80 percent of the drug is
eliminated renally as six metabolites
which have little or no antisecretory
activity. The other 20 percent of the
drug is excreted through the biliary
system. Although the elimination half-
life is about two to three hours (29),
the antisecretory action of omeprazole
can last up to 72 hours due to
prolonged proton pump binding (28).
Dosage adjustments are not necessary
in patients with renal impairment, and
omeprazole has no effect on renal
tubular handling of acid or on renal
electrolyte excretion (29). Although
dosage adjustment is unnecessary in
patients with hepatic impairment, liver
disease increases omeprazole’s
bioavailability and decreases its
clearance; nevertheless, these patients
should be monitored for adverse
effects.

One issue concerning widespread
use of omeprazole is its long-term
safety profile. In two-year studies in
rats, a dose-related increase in gastric
carcinoid tumors was seen, however,
data from patients with Zolinger-
Ellison Syndrome (ZES) who received
omeprazole for up to 4 years,
revealed no detectable carcinoid
tumors (30,31).

Omeprazole has few adverse
effects, but its most frequent
complaint is headache, which occurs
in approximately 7% of patients.
Diarrhea, abdominal pain, nausea,
upper respiratory infection, vomiting,
dizziness, and rash have also been
reported, but in less than 4% of
patients (28).

Since Omeprazole inhibits the
isoenzyme lie of the P-450 enzyme
system, it has the potential to interact
with other drugs metabolized by this
route (Table 7). In addition, a
catatonic reaction was reported in a
patient receiving disulfiram
(Antabuse®) and omeprazole (29).

The clinical significance of these
interactions has not been determined,
but close monitoring is recommended.
In addition, omeprazole increases
gastric pH so serum concentrations of
drugs that require an acidic environment
for absorption can be decreased (28,29).

Currently, the FDA has approved
omeprazole for severe erosive
esophagitis and for poorly responsive
symptomatic GERD, including patients
demonstrating an inadequate response
to H2RA therapy. Studies comparing
omeprazole once daily with H2RAs or
placebo have been favorable. In a
study of 230 patients with reflux
esophagitis, 74% of the patients on
omeprazole 20 mg/day and 75% of
patients on 40 mg/day were healed
after eight weeks, compared to 14% of
patients receiving placebo (32). Meta-
analysis of trials comparing
omeprazole (20 or 40 mg/day) with
ranitidine (300 mg/day) showed a
significantly better healing rate for
patients on omeprazole after four and
eight weeks (32).

Omeprazole has been shown to be
effective in patients with resistant
esophagitis despite H2RA therapy.
Ninety-eight patients with persistant
esophagitis after three months or
more of ranitidine or cimetidine
therapy were randomized to either
omeprazole 40 mg/day or ranitidine
300 mg twice a day. After 12 weeks,
90% (46 of 51 patients) receiving
omeprazole were healed compared to
47% (22 of 47 patients) on ranitidine
(p < 0.001) (33).

Bardhan and colleagues (34)
studied 45 patients with refractory
esophagitis despite at least three
months of either cimetidine 3-2
gm/day or ranitidine 900 mg/day.
These patients were subsequently
treated in an open trial with
omeprazole 40 mg/day for up to eight
weeks. After four and eight weeks,
healing occurred in 73% and 91% of
patients, respectively (32).

Dosing and length of therapy of
omeprazole are somewhat
controversial. Currently, only 20
mg/day is FDA-approved for GERD,
however, higher doses have been
used in refractory patients (35). The
manufacturer recommends that an
initial dose of omeprazole 20 mg/day
be used for at least four weeks before
considering increasing the dose to 40
mg/day (27). Length of treatment is
usually four to eight weeks, with an
additional four weeks if healing has
not occurred. Maintenance therapy
with omeprazole is effective, but
remains a concern due to the
appearance of gastric carcinoid
tumors in rats given high doses over
long periods of time.

Since it is acid labile, omeprazole is
composed of enteric-coated granules.
The capsules should not be crushed
or mixed with food or enteral feedings
(27), however, omeprazole granules
have been mixed with acidic fruit
juices for patients who cannot swallow
capsules or require administration via a
naso-gastric tube (16).

Due to its once daily dosing,
efficacy, and cost, omeprazole may
soon be considered as first line Phase
II therapy for GERD. A decision
analysis was performed to assess
clinical and economic effects of three
treatments; i.e., Phase I therapy alone
or in combination with either
omeprazole (20 mg/day) or ranitidine
(150 mg bid) therapy. Although the
omeprazole therapy was the most
expensive, it reduced GERD
symptoms and overall payments by
the third-party payor for treatment of
complications and surgery (36).
Comparing cost-effectiveness of
omeprazole (40 mg/day) and
ranitidine (300-600 mg/day) therapy,
omeprazole produced higher healing
rates as well as faster healing rates. In
addition, omeprazole-treated patients
used less antacids; projected
endoscopy use decreased because
clinicians had more confidence in
omeprazole's healing ability, so the
authors concluded that omeprazole was
more cost-effective than ranitidine (16).

514 THE WEST VIRGINIA MEDICAL JOURNAL

Sucralfate

Although sucralfate is used clinically
to treat GERD in some settings, this
agent is not FDA approved for GERD
treatment. Sucralfate is a sulfated
disaccharide complex with aluminum
hydroxide that adheres to damaged
mucosal tissue to create a barrier to
the irritant effects of acid, pepsin, and
other components of gastric contents.

It does not alter pH of the gastric
contents or affect gastric acid
secretion (27).

Since there is virtually no
absorption of sucralfate, adverse
systemic effects are uncommon.
Sucralfate is well-tolerated, with
constipation being the most
commonly reported adverse effect.
However, the aluminum in sucralfate
may be absorbed which can be a
potential problem in renally impaired
patients (37). Additionally, chronic
ingestion can result in increased
aluminum serum concentrations;
hypophosphatemia can occur
secondary to sucralfate binding of
dietary phosphate (2).

Sucralfate tablets can be swallowed
or dissolved in water to make a
suspension, and a suspension
fonnulation is now being manufactured.
Drug interactions with sucralfate
usually result from chelation by the
aluminum portion of the molecule
(Table 7). Drug-drug interactions may
be avoided by administering
medications at least two hours before
sucralfate administration (16).

Results of studies on sucralfate’s
efficacy in GERD have been
inconsistent. In a study of 18 patients
with esophagitis who received
sucralfate 1 gm four times daily, 94%
showed improvement after 12 weeks
(2). However, a multicenter,
randomized, double-blind, placebo-
controlled trial was unable to
demonstrate significant differences
between sucralfate suspension (1 gm
after meals and 2 gm at bedtime) or
liquid placebo treatment (38).

Although anecdotal reports suggest
that sucralfate is effective in some
patients, especially those with mild
esophagitis, further studies are
necessary to confirm its efficacy.

Prokinetic agents

Drugs that increase transit time of
material throughout the gastrointestinal
tract are called prokinetic agents.
Currently, the three prokinetic agents
available in the United States are
bethanechol (Urecholine®), a

cholinergic agonist; metoclopramide
(Reglan®), a dopamine-receptor
antagonist; and cisapride (Propulsid®),
a serotonin-4 (5-HT4) agonist.
Erythromycins also increase gastric
motility, but are not currently being
used for GERD treatment (39).

Bethanechol increases LES pressure,
amplitude of gastrointestinal
contractions, and esophageal
clearance, but it has no effect on
gastric emptying or coordination of
gastrointestinal contractions. For this
reason, bethanechol is sometimes not
considered a true prokinetic agent
(4,39). In addition, bethanechol can
increase gastric acid secretion which
could negatively affect a GERD patient

(5.39.40) .

Bethanechol is poorly absorbed,
taking up to 90 minutes before its full
gastrointestinal effects are seen (16).

In addition, patients do not tolerate
bethanechol well. Adverse effects are
related to its cholinergic actions and
include abdominal pain and cramps,
diarrhea, urinary frequency, blurred
vision, sneezing, sweating, salivation,
and increased blood pressure

(15.16.40) . Bethanechol is relatively
contraindicated in patients with
asthma, chronic obstructive
pulmonary disease, and peptic ulcer
disease (2).

Metoclopramide increases LES
pressure and gastric emptying.
Although data are conflicting,
metoclopramide may also increase
esophageal peristalsis and clearance
(2). Absorption is rapid and virtually
complete; however, it may take up to
60 minutes for the GI effects to occur
(16). The elimination half-life of
metoclopramide is 2.5 to 5 hours and
it is excreted in the urine (39).

As with bethanechol, metoclopramide
produces a number of adverse effects.
Drowsiness, jitteriness, tremors,
nightmares, anxiety, and depression
can occur. Neurologic and dystonic
reactions also have been reported
(4,16). Because metoclopramide can
alter GI transit time, absorption of
other drugs may be affected (Table 7).
Use of medications that decrease GI
motility' can hinder metoclopramide’s
effect. In addition, use with some
antihypertensives and other
medications that depress the CNS may
lead to enhanced CNS depression.

Cisapride, a newer oral prokinetic
agent, appears to have a more
favorable side effect profile than
metoclopramide. Its mechanism of
action is enhancement of release of
acetylcholine at the myenteric plexus.
In vitro, it acts as a serotonin-4 (5HT)

receptor agonist; this agonist action
may result in cisapride’s ability to
increase GI motility.

Cisapride is rapidly absorbed after
oral administration and peak plasma
concentrations are reached in 1 to Vh
hours. It is approximately 35%-40%
bioavailable, and about 98% bound to
plasma proteins. The recommended
dose of this medication is 10 mg four
times daily (28). In two placebo
controlled studies, 10 and 20 mg four
times daily showed beneficial effects
on nighttime regurgitation, however,
in another placebo controlled study,
these effects were not seen (41).

The advantage of cisapride appears
to be its better safety profile; the most
commonly reported side effects were
dizziness, vomiting, pharyngitis, chest
pain, back pain, depression,
dehydration and myalgia (all reported
to be greater than 1%) (28).

Study results with the currently
available prokinetic agents for GERD
treatment have been conflicting.
However, because of their poor
tolerability, these agents are not
commonly used alone, and are
primarily reserved for adjunctive
therapy with H2RAs (4).

Maintenance therapy

Once healing or symptomatic relief
has been achieved in GERD patients,
maintenance therapy frequently is
necessary. In patients with healed
esophagitis, as many as 80%-90%
experience relapse after six months
(33,42). Due to their established safety
profile during long-term therapy, the
H2RAs are most commonly used as
maintenance therapy in GERD patients
(4). However, typical maintenance
doses for duodenal ulcers (e.g.,
ranitidine 150 mg once daily) often
lead to relapse in many patients.

In a randomized, double-blind trial
of 6l patients with healed esophagitis,
relapse rates of 42%-36% occurred
after six months of ranitidine 150 mg
at bedtime and placebo, respectively
(43). In a 12-month comparative trial,
no significant differences in relapse
rates were seen in patients treated
with either placebo, cimetidine 300
mg twice daily, or cimetidine 400 mg
at bedtime (2,22). To prevent
recurrence, it appears that gastric acid
suppression must occur throughout
the day and night. Small studies have
shown that H2RA therapy at standard
peptic ulcer disease doses may
prevent relapse (22).

Omeprazole has also been studied
for possible maintenance therapy. In a
study of 73 patients with healed

DECEMBER 1994, VOL. 90 515

esophagitis, 19 percent (14 of 73
patients) experienced an
endoscopically-determined relapse
after six months of omeprazole 20 mg
once daily. Of these 14 patients, 12
healed after increasing the dose to 40
mg. once daily; the remaining two
patients healed after increasing the
omeprazole dose to 60 mg daily (43).
In a comparison of omeprazole (20
mg daily) with ranitidine (150 mg
twice daily), 25 percent of the
omeprazole-treated patients relapsed
after one year while more than 80
percent of the ranitidine-treated
patients suffered relapses (2).

Although omeprazole appears to be
effective in preventing recurrences,
concerns exist regarding omeprazole’s
long-term safety. Currently, peptic
ulcer disease treatment doses (divided
into multiple daily doses) of H2RA
therapy is the recommended therapy
for GERD prophylaxis (4,22,44).
Omeprazole should be reserved for
patients who fail H2 receptor antagonist
maintenance therapy. No studies have
yet determined the most appropriate
length of time a patient should remain
on maintenance therapy.

Conclusions

Proper identification of both the
classical and atypical presentations of
GERD need to be made to avoid
potential complications of untreated
disease such as hemorrhage,
obstruction, aspiration or malnutrition.
In mild cases, GERD can be treated
with antacid or alginic acid therapy, as
well as non-pharmacological measures;
with more severe disease, H2RAs or
omeprazole are recommended. These
drugs have proven efficacy in
suppressing gastric acid secretion and
in promoting healing of damaged
tissue in GERD patients.

The H2RAs need to be given at
least twice daily and, if necessary, in
high doses (e.g., ranitidine 600 to 900
mg daily) for at least eight weeks.
Omeprazole treatment should be
initiated at 20 mg daily for four to
eight weeks, although higher doses
may be necessary (e.g., 40 to 60 mg
daily). If healing has not occurred
after an eight- week trial, omeprazole
can be continued for another four
weeks. Maintenance therapy is often
necessary for GERD patients even
after healing has occurred; EI2RAs
in split doses or omeprazole once
daily can be used to prevent
disease recurrence.

References

1 Nehel OT. Fornes MF, Castell DO.
Symptomatic gastroesophageal reflux:
incidence and precipitating factors. Am J
Dig Dis 1976;21:953-6.

2. Welage LS. Chapter 28: Gastroesophageal
reflux In: DiPiro JT, Talbert RL, Hayes PE,
et al, editors. Pharmacotherapy: a
pathophysiologic approach. New York:
Elsevier Science Publishing Co, 1992:495-510.

3. Bozymski EM. Pathophysiology and
diagnosis of gastroesophageal reflux
disease. Am J Hosp Pharm 1993;50(Suppl 1):
S4-S6.

4. Rex DK. Gastroesophageal reflux disease in
adults: pathophysiology, diagnosis, and
management. J Fam Pract 1992;35(6):673-81.

5. Navab F, Texter EC Jr. Gastroesophageal
reflux: pathophysiologic concepts. Arch
Intern Med 1985;145:329-33.

6. Mittal RF, Lange RC, McCallum RW.
Identification and mechanism of delayed
esophageal clearance in subjects with hiatus
hernia. Gastroenterology 1987;92(1 ): 130-5

7. Kahrilas PH, Dodds WJ, Hogan WJ, Kern M,
Arndorfer RC, Reece A. Esophageal
peristaltic dysfunction in peptic esophagitis.
Gastroenterology 1986;92( 1 ): 1 30-5.

8. McCallum RW, Berkowitz DM, Lerner E.
Gastric emptying in patients with
gastroesophageal reflux. Gastroenterology
1981 ;80( 21:285-91 .

9. Katz PO. Disorders of the esophagus:
dysphagia, noncardiac chest pain, and
gastroesophageal reflux. In: Barker LR,
Burton Jr, Zieve PD, editors. Principles of
ambulatory medicine. Baltimore: Williams
and Wilkins, 1991.

10. Mold JW, Reed LE, Davis AB, Allen ML,
Decktor DL, Robinson M. Prevalence of
gastroesophageal reflux in elderly patients
in a primary care setting. Am I Gastroenterol
1991;86:965-70.

11 Kitchin LI, Castell DO. Rationale and
efficacy of conservative therapy for
gastroesophageal reflux disease. Arch Intern
Med 1991;151:448-54.

12. Day JP, Richter JE. Medical and surgical
conditions predisposing to gastroesophageal
reflux disease. Gastroenterol Clin North A
1990;19(3):587-607.

13. Traube M. The spectrum of the symptoms
and presentations of gastroesophageal
reflux disease. Gastroenterol Clin North A
1 990; 19( 3);609- 16.

14. Wu WC. Ancillary tests in the diagnosis of
gastroesophageal reflux disease.
Gastroenterol Clin North A 1 990 ; 1 9C 3 ) : 67 1 -
82.

15. Johnson DA Medical therapy for
gastroesophageal reflux disease. Am I Med
1992;92(Suppl 5AL88S-97S.

16. Garnett WR. Efficacy, safety, and cost issues
in managing patients with gastroesophageal
reflux disease. Am I Hosp Pharm 1993;50
(Suppl 1 ):S 1 1-S18. '

17. Konturek SJ, Brzozowshi T, Drozdowicz D.
Dembinski A, Nauert C. Healing of chronic
gastroduodenal ulcerations by antacids: role
of prostaglandins and epidermal growth
factor. Dig Dis Sci 1990;35(9):1 121-9.

18. Saunders DR, Sillery J, Chapman R. Effect of
calcium carbonate and aluminum hydroxide
on human intestinal function. Dig Dis Sci
1988;33(4):409-13.

19. Preclik G, Strange EF, Gerbver K, Fetzer G,
Horn H, Ditschuneity H. Stimulation of
mucosal prostaglanin synthesis in human
stomach and duodenum by antacid
treatment. Gut 1989;30:148-51.

20. Hollander D, Tarnawski A. Are antacids
cytoprotective? Gut 1989;20:145-7.

21. Hansten PD, Horn Jr. Drug Interactions and
Updates. Lea & Febiger: Alvem, PA 1990.

22. Garnett WR, Dukes, Jr GE. Chapter 19:

Upper gastrointestinal disorders. In: Koda-
Kimble MA, Young LY, Kradjan WA, and
Guglielmo BJ, editors. Applied therapeutics:
the clinical use of drugs, 5th ed. Vancouver,
WA: Applied Therapeutics, Inc., 1992:19-1 -
19-22.

23. Feldman M, Burton ME. Histamine-2-
receptor antagonists: standard therapy for
acid-peptic diseases (First of two parts). N
Engl J Med 1990;323(24):l672-80.

24. Lipsy RJ, Fennerty B, Fagan TC. Clinical
review of histamine-2-receptor antagonists.
Arch Intern Med 1990;150:745-51.

25. Sandmark S, Carlsson R, Fausa O, Lundell L.
Omeprazole or ranitidine in the treatment of
reflux esophagitis: results of a double-blind,
randomized, Scandinavian multicenter
study. Scand J Gastroenterol 1988;23:625-
32.

26. Collen MJ, Johnson DA. Correlation between
basal acid output and daily ranitidine dose
required for therapy in Barrett’s esophagus.
Dig Dis Sci 1992;37(4):570-6.

27. Hixson LJ, Kelley Cl, Jones WN, Tuohy CD.
Current trends in the pharmacotherapy for
gastroesophageal reflux disease. Arch Intern
Med 1992;152:717-23.

28. Olin BR, editor. Facts and comparisons. St.
Louis: Facts and Comparisons, Inc., 1993-

29. Massoomi F, Savage J, Destache CJ.
Omeprazole: a comprehensive review.
Pharmacotherapy 1993; 13(1 ):46-59.

30. Maton PN, Vinayek R, Frucht H, McArthur KA,
Miller LS, Saeed ZA, et al. Long-term
efficacy and safety of omeprazole in
patients with Zollinger-Ellison Syndrome: a
prospective study. Gastroenterology 1989;
97(4):827-36.

31. Buhl K, Clearfield HR. Omeprazole: a new
approach to gastric acid suppression. Am
Fam Phys 1990;41:1225-7.

32. Sontag SJ, Hirschowitz Bl, Holt S, Robinson
MG, Behar J, Berenson MM, et al. Two
doses of omeprazole versus placebo in
symptomatic erosive esophagitis: The U.S.
multicenter study. Gastroenterol 1992;
102:109-18.

33. Maton PN. Drug therapy: omeprazole. N Engl
J Med 1991;324( 141:965-75.

34. Bardhan KD, Morris P, Thompson M, Dhande
DS, Hinchliffe RFC, Jones RB, et al.
Omeprazole in the treatment of erosive
esophagitis refractory to high does cimetidine
and ranitidine. Gut 1990;31:745-9.

35. Robinson M, Maton PN, Allen ML, Humphries
TJ, McIntosh D. Cagliola AJ, et al. Effect of
different doses of omeprazole on 24-hour
oesophageal acid exposure in patients with
gastro-oesophageal disease. Aliment
Pharmacol Therapy 1991;5:645-51.

36. Hilman AL, Bloom BS, Fendrick M, Schwartz
JS. Cost and quality effects of alternative
treatments for persistent gastroesophageal
reflux disease. Arch Intern Med 1992;
152:1467-72.

37. Burgess E. Aluminum toxicity from oral
sucralfate therapy. Nephron 1991;59:523-4.

38. Williams RM, Orlando RC, Bozymski EM,
et al. Multicenter trial of sucralfate
suspension for the treatment of reflux
esophagitis. Am I Med 1987;83(Suppl
3BL61-6.

39. Reynolds JC and Putnam PE. Prokinetic
agents. Gastroenterol Clin North A 1992;
21L(3):567-96.

40. McCallum RW. Gastric emptying in
gastroesophageal .reflux and the therapeutic
role of prokinetic agents. Gastroenterol Clin
North A 1990;19(3):551-64.

516 THE WEST VIRGINIA MEDICAL JOURNAL

41. VanOutryve M, DeNutte N, VanEeghen P,
Goons JP. Efficacy of cisapride in functional
dyspepsia resistant to domperidone or
metoclopramide: a double-blind, placebo-
controlled study. Scand J Gastroenterol
1993; 195 (Suppl):47-52.

42. Hetzel DJ, Dent J, Reed TO, et al. Healing
and relapse of severe peptic esophagitis
after treatment with omeprazole.
Gastroenterology 1988;95(4):903-12.

43- Koelz HR, Birchler R, Brethoiz A, Bron B,
Capitaine Y, Delmore G, et al. Healing and
relapse of reflux esophagitis during
treatment with ranitidine. Gastroenterology
1986;91(5):1 198-1205.

44. Feldman M, Burton ME. Histamine-2-
receptor antagonists: standard therapy for
acid-peptic diseases (Second of two parts).
N Engl J Med 1990;323(25): 1749-55.

45. Spechler SJ, Department of Veterans Affairs
Gastroesophageal Reflux Disease Study
Group. Comparison of medical and surgical
therapy for complicated gastroesophageal
reflux disease in veterans. N Engl J Med
1992;326(1 2):786-92.

46. 1993 Drug Topics Redbook. Medical
Economics Data, Inc. Montvale, NJ.

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DECEMBER 1994, VOL. 90 517

Exercise Induced Anaphylaxis: One more
cause for syncope

MOLLY JOHN, M.D.

Assistant Professor, Department of Medicine,
Robert C. Byrd Health Sciences Center of WVU,
Charleston Division

Abstract

Syncope is a very common
problem. Young people who
exercise regularly are considered
to be in “good health , ” so when
they complain of passing out
during exercise, it must be treated
as a serious condition. Exercise
Induced Anaphylaxis (EIA ) is a
well known cause for syncope in
sports medicine and allergy
literature. A patient’s history > is
critical in making this diagnosis.
With the current exercise boom,
internists and family practitioners
need to be even more aware of EIA
when patients complain of
syncope with physical activity.

Case report

A 26-year-old attorney was brought
to the Emergency Room at CAMC,
General Division, in stable condition
after “almost passing out” following a
vigorous game of basketball. He had
not experienced any chest pain or
palpitations during the game,
however, a physician friend who was
playing with him noted that his pulse
was in the upper 90's and regular, but
that his blood pressure was not
palpable. His BP became normal after
2,000 cc. of Ringer’s Lactate solution.

On examination, he had urticarial
lesions on his trunk which responded
to intramuscular diphenhydramine. He
was kept on telemetry overnight and
no arrhythmia was noted. He told the
physicians he had experienced
syncope three months previously after
a game of basketball and near
syncope two times in 1989, once
while playing baseball and once while
jogging. He also reported that he had
noticed pruritic hives appearing on his
body recently, as well as in 1989
when he experienced the two
episodes of near syncope.

Family history revealed that his
father had many allergies. Physical
examination and routine tests were
within normal limits. He underwent a
stress echocardiogram and a tilt table
test which were both within normal

limits. A diagnosis of EIA was strongly
considered at this time, and an
allergist who examined the patient
later agreed the history was strongly
suggestive of EIA.

This patient decided to continue to
exercise. He jogs in the morning now
and always carries an Epipen. He
takes hydroxyzine in the evening.

Discussion

EIA was first described in 1979 as
three separate entities (1). One form is
Cholinergic Urticaria (CU), in which
patients develop small papular
eruptions associated with each bout of
exercise. These eruptions can be
precipitated by heat, as when taking a
warm shower. Wheezing may also
occur. This does not progress to
anaphylaxis.

Individuals with the second type or
classic EIA develop large urticarial
lesions. This does not happen each
time the patient exercises, but
whenever it does occur, it is always
associated with exercise. Symptoms of
pruritus, urticaria and flushing can
progress to angioedema or vascular
collapse. They can also have profuse
sweating, colic, respiratory symptoms
and a headache. This cannot be
precipitated by passive warming. It is
difficult to make a diagnosis of both
CU and classic EIA under controlled
conditions. Both can cause an increase
in serum histamine levels. A third kind
of EIA is a variant type in which the
individual has skin lesions similar to
CU but can progress to anaphylaxis.

Two-thirds of the patients with EIA
have a family history of atopy (2).
Females are more frequently affected,
especially during their menstruation.
The mean age of onset is around 25
years, but varies from age 4 through
80 (1).

Jogging is the most frequently
mentioned activity associated with
EIA, though any vigorous physical
activity can cause this condition.
Usually symptoms develop when the
patients are approximately five
minutes into the exercise. Patients can
very often predict when an attack is
going to occur, and 54% of patients
with classic EIA report eating celery,
shellfish or wheat 20 minutes to one
hour before an episode occurs (1).
Drugs like aspirin or NSAIDS can also
precipitate an episode.

Treatment for an acute attack
involves mainly the same regiment as
any anaphylactic reaction, i.e.
epinephrine, fluids and maintenance
of the airway. Prevention is more
important. Patients should be well
educated about their condition and be
told that avoiding exercise is the safest
alternative (even though this is not
acceptable to many patients), and
how to use an anaphylaxis kit
(Epipen). The Epipen kit should be
carried whenever they exercise, and
they should exercise with a person
who knows how to administer the
medications contained in the kit. In
addition, patients should be instructed
not to exercise after ingestion of food,
aspirin or NSAIDS, and females should
not exercise during menstruation.

Antihistamines like diphenhydramine
and hydroxyzine are somewhat
effective in the prevention of EIA, but
the side effects are not acceptable to
many patients. Newer antihistamines
have been tried with varying success,
and cromylyn sodium (Intal) does
help in some patients (3).

Individuals with EIA may also
benefit from regular exercise since
they may induce tolerance to exercise,
manifested by reduced peak histamine
levels and EIA symptoms (1). Recently,
a mention of the association of H.
pylori infection and EIA was made by
Dr. Steven Kagen at the Annual Meeting
of the American Academy of Allergy
and Immunology.

References

1. Nichols AW. Exercise Induced Anaphylaxis
and urticaria. Clinics in sports medicine
1992;11:303-10.

2. Briner WW Jr., Sheffer AL. Exercise Induced
Anaphylaxis. Medicine and Science in Sports
and Exercise 1 992; 24(81:849-50.

3. Briner WW Jr., Bruno PJ. Case report: 30-
year-old female with EIA. Medicine and
Science in Sports Exercise 1991:23(9)991-4.

4. Internal Medicine and Cardio News 1994,
April 15.

518 THE WEST VIRGINIA MEDICAL JOURNAL

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By this time, I hope that you are
already aware that my health project
for the WVSMA Alliance this year is
“ Combating the Negative Effects of the
Media on Children and Youth." It is
frightening how pervasive the
negative effects of media have
become in our society over the last
20-30 years, and WE MUST PUT A
STOP TO IT in order to save today’s
children from a further deterioration
of life as we’ve known it!

Perhaps you aren’t aware of the
extent of this problem. If you are not,

I urge you to read the fall issue of the
AMA Alliance’s magazine FACETS.
cover to cover. At this time though, I
would like to discuss another problem
which had arisen as a result of the
“information age” - - the exposure of
children to pornography through “
on-line computer services!”

If you have children or
grandchildren, or children you care
about who are using online computer
services, you need to be aware of
what they may be accessing. Even
though computers are educational
tools that our children should have
access to, the computer networks are
becoming saturated with pornography
and “your” kids may be signing on!

The August issue of Woman ’s Day
magazine had an article entitled
“ Password-Pom ” that I’d like to
highlight for you. This article stated
that computer-saavy children are
being exposed to many things which
parents literally can’t conceive of - -
from grabbing erotic photos off of
phone lines to engaging in “cybersex”
(having sexually explicit conversations
with other users).

The technology behind this new
menace is NETWORKING, the process

President’s Page I

Protecting our children

of connecting computers to one
another through the telephone lines.
Networking is the system that forms
the backbone of the “information
superhighway,” an incredible
advancement for society, yet a
dangerous one because it allows your
children to invite the entire world into
your home through your personal
computer! The vast information
superhighway is a very scary place
because there is absolutely NO
regulation or control over it, and most
parents have no idea what’s out there
or how easy programs can be accessed.

On the uncensored global computer
network known as Internet, users are
swapping X-rated photos, trading
sexually explicit stories, and joining
discussion groups on topics ranging
from how to steal credit-card numbers
to bestiality and incest. It is shocking
that 150.000 accounts are now in
schools, and that number is expected to
grow to 1.5 million within three years!

There is no way to totally block
access to these types of programs
because there is no centralized
management of Internet resources. In
addition, there is literally no one to
complain to about Internet because it
is barely organized at all; it’s merely
an interconnection of computer
networks around the world, with no
central authority!

Some examples of other problems
created by “on-line” services:

— In the “anarchy files” on Internet
and other electronic sources, children
can easily find instructions on how to
build pipe bombs or cause other kinds
of mayhem.

— Computers are increasingly
being used by child molesters to find
and meet their young victims;

— Children often innocently
wander into inappropriate areas
while on-line because they are misled
by innocuous sounding names. One
example was an 8-year-old girl who
was discovered in an electronic
discussion group called “ TV Chat."
This girl thought the group was going
to be talking about TV, but it was
really discussing transvestites!

The first and most important rule of
computer safety is; Don't ever allow
your child to give out personal
information on-line! Computer
communication is anonymous; you
never really know to whom you are
talking, consequently, your children
should be taught never to give their
real names, addresses or phone
numbers to anyone they meet on-line.

Also, be careful to keep close tabs
on your children’s on-line activity.
Parents who vigorously monitor their
children’s TV watching and would
never dream of leaving a 7-year-old
alone at a shopping mall, might not
think twice about letting that same
child go on-line alone for hours at a
time. If your child is tying into any
bulletin boards with your computer,
you should supervise what he or she
is doing, whether they are 7 or 17
years old.

SO, WHO’S PROTECTING OUR
CHILDREN?

The future of today’s children is in
our hands! It is up to us as parents
and leaders in our communities to
help protect our children from the
many negative influences surrounding
them.

Sue Bryant

WVSMA Alliance President

520 THE WEST VIRGINIA MEDICAL JOURNAL

Editorial

—

Battle of the

Editor’s Note: Dr. Glover is a
professor of obstetrics and
gynecology at the Robert C. Byrd
Health Sciences Center of West
Virginia University. He served in
the Korean War and has been a
military historian ever since his
days in the service.

At 0530 on Saturday, December 16,
1944, the U.S. VIII Corps front in the
Ardennes - - a sector that had been
inactive for several months - -
suddenly became engulfed in a
massive artillery barrage. Within
hours, 25 German infantry and Panzer
divisions overwhelmed the American
defenders on an 85-mile front (1).
Hitler’s last great counteroffensive of
World War II had begun.

A drive from the German border
through the Ardennes to Antwerp (a
distance of 100 air miles) would trap
the British and Canadians as well as
the U.S. First and Ninth Armies, fully
half of the Allied forces on the
Continent. If successful, such an
offensive could lead to a second
Dunkirk. Optimistically, Hitler believed
he could then make peace on terms
acceptable to the Third Reich (2).

The VIII Corps sector was being
used by the First U.S. Army to rest
battle-worn divisions and to introduce
green ones to combat. Two of the
corps’ three divisions had recently
been relieved from combat after
sustaining heavy casualties (3). A
third, the 106th Infantry Division, had
embarked from the U.S. on the 20th of
October and arrived on line just six
days before the attack (4).

The Germans attacked with three
armies and had a numerical advantage
of 250,000 to 83,000 men, as well as
numerical superiority in artillery and
armor (5). They achieved complete
surprise. In short order, one American
division was destroyed, two others
were crippled, and an armored
combat command was eliminated.
Thousands of American soldiers were
killed, wounded, or captured.
Nevertheless, the timetable for the
attack almost at once fell behind
schedule, largely due to the tenacity
of individual American units (6,7).

Bulge: A remembrance

Bastogne was the key to the entire
road net on the southern flank of the
German advance. Continued
occupation, therefore, was essential
for the Allies to mount a counter
attack. General Eisenhower’s strategic
reserve consisted solely of the 82nd
and the 101st Airborne Infantry
Divisions, so on December 19 he
ordered both divisions into action and
moved the 101st Airborne to Bastogne
to set up defensive positions (8).

Medical support for the division was
provided by the 326th Airborne
Medical Company, which was
organized and equipped for self-
sufficient operations out of contact
with the normal ground chain of
evacuation. Both collecting and
clearing elements were included in its
structure, and an auxiliary surgical
team was attached so the unit could
function as a field hospital.

Anticipating that the German attack
would come from the east, the
medical company commander set up
the clearing and surgical station eight
miles to the west of Bastogne, well to
the rear of the anticipated action (9).

On that evening of December 19, a
German armored reconnaissance force
that had bypassed Bastogne caught
the medical company by surprise and,
after a brief fire fight, accepted their
surrender. The commanding officer
and his staff, the entire auxiliary
surgical team, and 130 officers and
men from the unit were taken
prisoner (10). Adversity eliminated the
principal medical support of the 101st
Airborne Division before it could
become fully operational. Two days
later the Germans closed the ring.
Bastogne was completely surrounded.

The situation was deplorable. The
weather was bitterly cold and
everything was in short supply. Those
still fit to fight relinquished blankets to
protect their wounded comrades from
exposure. Artillery ammunition was
nearly expended. Yet, despite
concentric attacks by three German
divisions, the “Battered Bastards of
Bastogne” held on (11).

To commemorate the 50th
anniversary of the Ardennes
counteroffensive, a feature article

appears on page 506 in this issue of
the West Virginia Medical Journal
focusing on the achievements in that
battle of Dr. Henry M. Hills Jr., a
well-known Charleston orthopedic
surgeon. This is indeed appropriate,
because the outcome of the Battle of
the Bulge (which actually hastened
the German defeat) was as much a
result of small unit actions and the
dogged determination of the
individual American soldier as it was
of command decisions.

References

1. Marshall SLA. Bastogne: The First Eight Days.
Washington, DC: The Infantry Journal Press,
1946:4-5.

2. MacDonald CB. A time for trumpets: The
untold story of the Battle of the Bulge. New
York: William Morrow, 1985:28-9.

3. Cole HM. The Ardennes: Battle of the Bulge.
Washington, DC: Office of the Chief of Military
History, United States Army, 1965:55-7.

4. Whiting C. Death of a division. New York:
Stein and Day, 1981:10.

5. Cavanagh WCC. Krinkelt-Rocherath: The
Battle for the twin villages. Norwell, MA:
Christopher Publishing House, 1986:4.

6. Devlin GM. Paratrooper! The saga of U.S.
Army and Marine parachute and glider
combat troops during World War II. New
York: St. Martin’s Press, 1979:519.

7. Von Luttichau CVP. The German
counteroffensive in the Ardennes. In:
Command Decisions. Office of the Chief of
Military History, Department of the Army,
Washington, DC, 1959:355-6.

8. Devlin, GM. Paratrooper! The saga of U.S.
Army and Marine parachute and glider
combat troops during World War II. New
York: St. Martin's Press, 1979:522.

9. Cosmas GA, Cowdrey AE. Medical service in
the European Theater of operations.
Washington, DC: Center of Military History,
United States Army, 1992:393-4.

10. Cosmas GA, Cowdrey AE. Medical service in
the European Theater of operations.
Washington, DC: Center of Military History,
United States Army, 1992:415-9.

11. The papers of Dwight David Eisenhower.
The war years IV. Alfred D. Chandler Jr.,
editor. Baltimore: The Johns Hopkins Press,
1970:2376.

DECEMBER 1994, VOL. 90 521

In My Opinion

Managed care = veterinary care

West Virginia is becoming more and more affected by
the managed care mania which is sweeping the country.
Doctors are scrambling to understand and adjust to the
new environment. Implicit in the development is the notion
that health care costs will be lowered, but there is a
paucity of data that this is so. Nationwide at least 25% of
the insured population are in HMOs and many more are
in managed care plans -- with no discernable savings
to date.

The Congressional Budget Office has concluded that
there is no evidence that managed care saves money. A
study of Medicare recipients in HMOs concluded that it
costs the government 6% more than in private, fee-for-
service plans, despite the fact that the payment to the
HMOs was pegged at 95% of average Medicare
disbursements. The explanation is that the HMOs enrolled
the Medicare recipients who are 65-70 years of age and
still working, and not the 85-year-old nursing home
residents.

Even though the Clinton administration has boosted
managed care by utilizing 500 “experts” who were all in
managed care to help plan the president’s proposal for
health care reform, the real push comes not from the
politicians, not from the patients, certainly not from the
doctors and other providers, but solely from the insurance
companies. Managed care does not lower the cost of care,
however, it does lower the percentage going to the provider
and increases the cost of administration, already the biggest
in the world and a major cause of the present problem.

Understanding managed care is not difficult if you
understand the concepts of veterinary medicine. In veterinary
medicine, it matters not what the patient wants - it only
matters what the owner wants. So, it is in managed care --
the insurance companies talk and act as if they own the
patients and behave accordingly.

In veterinary medicine, the size of the herd is critical.
The man with 100 head of cattle gets more consideration
than the little girl with her kitten. In managed care, they
talk of “covered lives;” the more employees you have in
your company, the bigger the discount your company will
receive from standard prices.

Veterinary care is also a great equalizer. Even if you just
won the Kentucky Derby, if you break your leg you will
be shot. The parallels are that end-of-life decisions are
now more likely to be dictated by the managed care plan
and the CEO of the company will, presumably, be treated
the same as the janitorial staff.

In veterinary care, the same medicines used in human
medicine are far cheaper. This is particularly true of farm
animals raised for food as opposed to pets because there
are definite fiscal constraints on medical care. This same
principle applies with managed care, where the cheapest
therapy is the preferred choice.

In human medicine, the detailed history is 85% of the
diagnostic armamentarium. In veterinary medicine if there
is no history, the history and the treatment recommendations
are given by the owner. Objective criteria are more
important. Managed care, too, tends to discount the
individual history. Cases must be pigeonholed into CPT or
ICD-9 categories and dealt with accordingly.

Managed care will destroy the physician-patient
relationship. In veterinary care, there is only a superficial
relationship between the veterinarian and the animal. The
major relationship is with the owner -- the payor for care.

To be fair, there are differences. Veterinary care tends to
be cash and carry with a minimum of paperwork and
insurance forms. Managed care is a thicket of regulations,
paperwork, rules, penalties, traps, evasion and obfuscation.

What is the solution? Over the last two to three decades,
medicine and all social institutions have gradually become
larger and larger entities. The ability of a solo practitioner
to modify the terms of a managed care contract to which
he/she objects is nearly zero. Doctors must organize and
band together either loosely or formally to negotiate as a
group. Furthermore, we must educate our patients — they
have more clout than we have with their employers, and
therefore, their insurance programs. Finally, we must push
the concept of medical savings accounts as a viable
alternative. The politicians say it is politically unattainable
and unworkable, however, it is working for the employees
of the Golden Rule Insurance Company, for the citizens of
Jersey City, N.J., and in the state of Idaho.

Managed care is social engineering that makes George
Orwell, the author of 1984, look like a British optimist.
Managed care is an oxymoron: the people doing the
managing are opposing those who do the caring. We
must remember, we are physicians, not veterinarians.
Whether we succeed or not, we must preserve the
traditions of medicine that have endured for centuries and
made doctors the most eminent champions of humankind.

Wallace D. Johnson, M.D.

Beckley

522 THE WEST VIRGINIA MEDICAL JOURNAL

Mark Your Calendars!!
Please Attend

General News

At Mid-Winter

Session on controversies to discuss
coronary artery disease, mammography

This year’s Second Scientific Session,

“ Controversies in Medicine ,” at the
WVSMA/WVACP’s 1995 Mid-Winter
Seminars and Scientific Conferences
will be devoted to the pros and cons of
“ Screening Mammography" and the
medical vs. surgical treatment of
“ Coronary Artery Disease." This session
will take place on Saturday, January 21
at 9 a.m. at the Radisson Hotel in
Huntington.

The pros of screening mammography
will be addressed by Judy Schreiman,
M.D., a professor and vice chair of the
Department of Radiology at the WVU
School of Medicine in Morgantown;
and the cons on this subject will be
presented by Daniel S. Foster, M.D., a
clinical professor in the Department of
Surgery at the WVU School of Medicine,
Charleston Division. Discussing the
medical treatment of coronary artery
disease will be Robert C. Touchon,
M.D., a professor of medicine and
physiology at Marshall University, and
Ronald C. Hill, M.D., an associate
professor of surgery at the WVU School
of Medicine in Morgantown, will lecture
on the surgical treatment of this disease.

Information about these speakers
begins below. A registration form for the
conference appears on page 527, and
more details about the meeting can be
obtained by phoning Nancie Diwens at
(304) 925-0342.

Session presenters highlighted

Dr. Schreiman is a native of
California, who received a nursing
degree from San Jose State University in
1972. After nursing school, she earned
her A.S. and P.A. certification from
Foothill College/Stanford University
Medical Center and then enrolled in
Michigan State University, where she
obtained a B.S. degree in psychology in
1976 and her medical degree in 1980.

Following medical school, Dr.
Schreiman did a four-year residency in
diagnostic radiology at the Mayo Clinic
and became an instructor in the
Department of Radiology at the

University of Minnesota. In 1985, she
was promoted to assistant professor at
the University of Minnesota, but she
left the next year to accept the posts of
assistant professor and director of the
residency program in the Department
of Radiology at Creighton University in
Omaha, Neb.

In 1989, Dr. Schreiman was named
vice chair of the Department of
Radiology at Creighton, and she was
elevated to associate professor. She
was on the faculty at Creighton until
1992, when she relocated to West
Virginia to become professor and vice
chair of the Department of Radiology
at the WVU School of Medicine. In
addition to this role, Dr. Schreiman is
also section chief of mammography at
WVU and medical director of the
Betty Puskar Breast Care Center.

A diplomat of the American Board of
Radiology, Dr. Schreiman is a member
of many professional radiological
organizations and is currently the
investigator or principal investigator for
four grant projects involving breast
cancer education and research.

Dr. Foster was born in Oak Ridge,
Tenn. He received a B.A. degree from
Haivard University in 1970 and his
medical degee in 1974 from the Stanford
University School of Medicine.

After completing his internship at
Charity Hospital of Louisiana at New
Orleans and a residency in surgery at
Tulane University, Dr. Foster went into

private practice for general and vascular
surgery in Charleston. Since he opened
his practice in 1979, he has also been
on the faculty of the WVU School of
Medicine as a clinical professor in the
Department of Surgery.

A fellow of the Southeastern
Surgical Congress and the American
College of Surgeons, Dr. Foster is also
a member of several other medical
organizations including the Alton
Ochsner Surgical Society, the West
Virginia Gastrointestinal Society, and
the Tulane Surgical Society. He is also
chairman of the WVSMA's Mid-Winter
Clinical Conference Committee and is
a member of the WVSMA's Committee
on Medical Education.

Dr. Touchon earned his medical
degree from Saint Louis University in
St. Louis in 1965. He did residencies in
internal medicine at Santa Barbara
General/Cottage Hospitals in Santa
Barbara and at the University of
Pennsylvania

After his residencies. Dr. Touchon
was a fellow in clinical cardiology from
1968-69 at Saint Vincent Hospital at the
University of Southern California. He
then completed a fellowship in
cardiology research at the University of
California at Los Angeles.

In 1970, Dr. Touchon joined the U.S.
Air Force and served for two years as a
medical corp flight surgeon, as well as
the director of the catherization lab and
chief of the cardiopulmonary research

524 THE WEST VIRGINIA MEDICAL JOURNAL

function at Brooks Air Force Base in
Texas. During this time, he also taught
physiology and medicine at the
University of Texas Medical School in
San Antonio.

Following his military service, Dr.
Touchon returned to California to
accept a position as medical director of
the Cardiac Diagnostic Institute in
Fullerton. In 1974, he was named
director of cardiac rehabilitation at the
institute, and in addition became
director of coronary care at Anaheim
Memorial Hospital in Anaheim. From
1975-77, Dr. Touchon held a variety of
management roles at the two facilities
and was a clinical instructor of medicine
at the University of California at Irvine.

In 1978, Dr. Touchon relocated to
Colorado to become director of
intensive care at Mercy Medical Center
in Durango, where he also later served
as chief of medicine. Four years later,
he moved to Huntington to accept his
current posts as chief of cardiovascular
medicine at the Marshall University
School of Medicine and chief of
cardiology at the VA Medical Center. In
addition, since 1985 Dr. Touchon has
been a professor of medicine and
physiology at MU, and since 1988 has
been director of cardiac rehabilitation at
Cabell Huntington Hospital.

A fellow of the American College of
Cardiology, Dr. Touchon is presently
the governor of the West Virginia
Chapter of this organization.

Dr. Hill was bom in Parkersburg
and received his M.D. degree from
WVU in 1974. He did a two-year
residency in general and thoracic
surgery at Duke University Medical
Center, and then became a research
fellow with the NIH Academic Surgical
Scholar Research Training Program at
Duke for three years.

After his fellowship, Dr. Hill was the
senior resident in general and thoracic
surgery at Duke until 1983, when he
was named chief resident. The next
year, he joined the faculty as a teaching
scholar in cardiac surgery and an
instructor in surgery.

In 1985, Dr. Hill relocated to
Morgantown to become an assistant
professor of surgery at the WVU School
of Medicine and a consultant at the VA
Medical Center in Clarksburg. Two years
later, Dr. Hill took on additional duties
as an attending cardiothoracic surgeon
at Monongalia General Hospital, and in
1990 he was promoted to associate
professor of surgery at WVU.

In 1994, Dr. Hill was elected to Best
Doctors in America. A noted author and
researcher. Dr. Hill has published over
100 abstracts, chapters and articles, and
has over 20 studies now in progress.

Third Mid-Winter session to
focus on treatment of STDs

“ Sexually Transmitted Diseases in
Women and Adolescents” will be the
title of this year’s Third Scientific
Session on Saturday, January 21 at
2 p.m. during the WVSMA/WVACP’s
1995 Mid-Winter Seminars and
Scientific Conferences at the
Radisson Hotel in Huntington.

Topics for this session include
“ Human Papilloma Virus Infections, ”
“AIDS, ” “Update on Sexually
Transmitted Diseases, "and “Herpes
Virus and Other STDs. "Addressing
these respective subjects will be
Thomas Rushton, M.D., an assistant
professor of medicine at the Marshall
University School of Medicine; Robert
B. Belshe, M.D., a professor of
medicine and pediatrics at the St.

Louis University School of Medicine;
Melanie A. Fisher, M.D., an associate
professor of medicine at the WVU
School of Medicine in Morgantown;
and Brant L. Viner, M.D., an assistant
professor of medicine at the University
of Massachusetts Medical Center.

Dr. Rushton is a Miami native who
received his M.D. degree from the
University of South Florida College of
Medicine in Tampa in 1989. He did his
internship and residency in internal
medicine at Vanderbilt University
Medical Center.

Dr. Ruston recently completed a
two-year fellowship in infectious
diseases and topical medicine at the
University of South Florida College of
Medicine before accepting his
current post as an assistant professor
of medicine at Marshall University. A
diplomate of the American Board of
Internal Medicine and the National
Board of Medical Examiners, Dr.
Rushton is a member of the Christian
Medical and Dental Society and the
American College of Physicians.

Dr. Belshe is a native of Hartford,
Conn., who earned his medical
degree from the University of Illinois
College of Medicine, where he also
completed his internship and
residency. Following his residency,

Dr. Belshe accepted a position in
1975 at the National Institutes of
Health as a research associate in the
National Institute of Arthritis and
Infectious Diseases.

After three years at the NIH, Dr.
Belshe joined the Department of
Medicine at the Marshall University

Fisher

School of Medicine as an associate
professor and chief of the Section of
Infectious Diseases. He was promoted
to professor of medicine in 1983 and
also held the position of professor of
microbiology. While on the faculty at
Marshall, Dr. Belshe spent a year on
sabbatical at the National Institute for
Medical Research in London.

In 1989, Dr. Belshe assumed his
current roles as a professor of
medicine and pediatrics and director
of the Division of Infectious Diseases
at the St. Louis University School of
Medicine. A fellow of the American
College of Physicians, the Infectious
Diseases Society of America, and the
American Academy of Microbiology,
Dr. Belse is a noted author who has
written over 120 articles and chapters.

Dr. Fisher received her M.D.
degree from the Milton S. Hershey
Medical Center of Pennsylvania State
University in 1977. She completed an
internship and residency at WVU, and
then joined the faculty for a year as an
assistant professor of medicine in the
Section of Comprehensive Medicine.

From 1982-84, Dr. Fisher was a
clinical and research fellow in
infectious diseases at the Hospital of
the University of Pennsylvania in
Philadelphia. After her fellowship, she
returned to WVU to be an adjunct
assistant professor of medicine in the
Section of Infectious Diseases.

In 1989, Dr. Fisher was promoted
to adjunct associate professor of
medicine at WVU, and in 1991 she
was promoted to her current position
as associate professor of medicine. In
addition, for over two years, she has
been the interim chief of the Section
of Infectious Diseases at WVU. Last
year, Dr. Fisher was recognized for
her outstanding teaching efforts by
the WVU Department of Medicine.

Belshe

DECEMBER 1994, VOL. 90 525

Dr. Viner received an A.B. degree
in romance languages and literatures
from Amherst College in 1973, and the
following year obtained an M.A.
degree in Spanish and Portuguese from
the University of Wisconsin. He
continued his education in romance
languages and literatures in 1974 at
Harvard University, where he worked
as a teaching fellow until 1979 when
he was accepted at the Boston
University School of Medicine, where
he earned his M.D. degree in 1983.

Dr. Viner completed an internship
and residency in internal medicine at
Boston City Hospital. In 1986, he
continued his postgraduate studies
with a two-year fellowship in the
Division of Infectious Diseases at the
Boston University School of Medicine.
After completing his fellowship, Dr.
Viner joined the faculty at the
University as an assistant professor of
medicine, and this year he was
promoted to his current role as an
assistant profesor of medicine.

Medical Assurance
president visits
component societies

Derrill Crowe, M.D., president of the
WVSMA’s newly endorsed medical
malpractice insurer Medical Assurance
of West Virginia, Inc., recently visited
several component societies to inform
members about the company and the
programs and services it offers.

In Dr. Crowe’s presentations, he
stressed Medical Assurance’s financial
stability and it’s long-tenn commitment
to WVSMA members. He reminded
members that Medical Assurance has a
proven track defense success record,
recording defense successes in more
than 93% of its cases. He also pointed
out that Mutual Assurance maintains a
“consent-to-settle” clause in its policy,
something many other carriers do not
offer to policyholders.

While visiting the component
societies, Dr. Crowe also explained
that Medical Assurance doesn’t require
that physicians make a surplus
contribution prior to being insured.
Since Medical Assurance is rated A+
(Superior) by A. M. Best, the
company’s financial strength means it
doesn’t require additional, non-
deductible contributions from its
policyholders. He also stated that the
company is tenatively planning seven
loss control seminars for 1995.

For more details about Medical
Assurance, contact WVSMA Executive
Director George Rider at (304) 925-0342.

WVHA Award Winner

At the WVSMA’s recent Council Meeting, Dr. James Comerci, WSMA Council Chairman was
presented the West Virginia Hospital Association’s Distinguished Service Award by WVHA
President Steven Summer in honor of his exceptional leadership in addressing West
Virginia’s health care issues.

Graeber to speak at Surgery Section meeting

Graeber

Geoffrey Graeber,
M.D., professor of
surgery in the
Section of
Cardiovascular and
Thoracic Surgery at
WVU, will be the
speaker for this
year’s WVSMA
Surgery Section
breakfast meeting at
8 a.m. on Sunday,
lanuary 22 at 8 a.m. during the
WVSMA/WVACP’s 1995 Mid-Winter
Seminars and Scientific Conferences.

Dr. Thomas Chang, chairman of the
WVSMA’s Surgery Section, is inviting all
interested physicians and other health
care professionals to attend Dr.

Graeber’s lecture on “We Current Status
of Video- Assisted Thoracic Surgery. ”

Dr. Graeber received his M.D. degree
from the State University of New York in
1971, and then did a surgical internship
and a residency in surgery at Johns
Hopkins Hospital in Baltimore. From
1973-78, he continued his postgraduate
studies at Upstate Medical Center in
Syracuse, N.Y., with residencies in
general and thoracic surgery.

Following his residencies, Dr.
Graeber served from 1978-89 with the
U.S. Army at the Walter Reed Army
Medical Center in Washington, D.C.,
and obtained the rank of colonel.
During most of this time, Dr. Graeber
was also on the faculty of The
Uniformed Services University of the
Health Sciences in Bethesda, M.D.

In 1989, Dr. Graeber relocated to
Morgantown to accept his current
posts as a professor of surgery and
director of surgical research at WVU.
In addition to his academic
responsibilities, Dr. Graeber is a staff
thoracic surgeon at both Ruby
Memorial Hospital and Monongalia
General Hospital, and he serves as a
consulting surgeon at Washington VA
Medical Center in Washington, D.C.,
and at the National Cancer Institute in
Bethesda, Md.

Dr. Graeber is a fellow of the
American College of Chest Physicians
and the American College of Surgeons.
He is noted author who has published
over 150 abstracts, articles and chapters.

To make reservations to attend this
breakfast meeting, please contact
Nancie Diwens at (304) 925-0342.

526 THE WEST VIRGINIA MEDICAL JOURNAL

( >

The Excitement is Snowballing...

Join us for the

1995 Mid- Winter Seminars and
Scientific Conferences

January 19-22, 1995

Radisson Hotel - Huntington
'

1995 Mid- Winter Registration Form

Name

Phone

Address

Citv State Zip Code

Payment by: Check Visa MasterCard

Card Number

Conference Cost: WVSMA member $125

non-member $175

Lunch & Learn Physician $50 —

spouse/student $35

TOTAL —

Conomikes Thursday, January 19

9 a.m. - noon "Reception and Patient Flow Techniques"
(Lunch on your own)

Expiration Date j . 4 p m

Signature

If paying by check, please send registration form and check to:

West Virginia State Medical Association

P.O. Box 4106
Charleston, WV 25364
(304) 925-0342

"Better Collections, Billing and Insurance Methods"

morning only $95

afternoon only $95

both sessions $185

TOTAL

Continuing Medical Education

Listed on this page are some of the
upcoming CME programs which will be
held in the state. Unless otherwise
noted, the events are presented at the
location under which they appear.

CabeU County Medical Society -
Huntington

January 12

“Recognizing and Treating
Depression,” Jeff Kelsey, M.D.,
Gateway Holiday Inn, 6:30 p.m.

Robert C Byrd Health Sciences
Center of WVU - Charleston

January 19

(Teleconference) “Cardiovascular
Intervention,” Mark C. Bates, M.D.

February 2

(Teleconference) “Opportunistic
Infections in HIV Disease,” Elizabeth
A. Funk, M.D.

February 16

(Teleconference) “Obstetrical
Ultrasound: Tips and Techniques,”
David A. Chaffin, M.D.

Robert C Byrd Health Sciences
Center of WVU - Morgantown

January 27-29

“2nd Annual Critical Care to
Rehabilitation Conference: A
Pulmonary Focus” (sponsored by the
WVU School of Medicine, Dept, of
Medicine, and MountainView
Regional Rehabilitation Hospital),
Snowshoe

January 27-29

“Advanced Life Support for
Obstetrics” (sponsored by the WVU
Dept, of Family Medicine and
Preston Memorial Hospital),
Morgantown

January 27

“The Ethics and Law in West Virginia
of Health Care Decision Making for
Incapacitated Patients” (sponsored by
the WVU Center for Health Ethics
and Law), Flatwoods

West Virginia State Medical
Association - Charleston

January 19-22

WVSMA/WVACP’s Mid-Winter
Seminars and Scientific Conferences,
Radisson Hotel, Huntington

Outreach Programs

Key to Sponsors

★ Robert C. Byrd Health Sciences Center
of WVU, Morgantown

□ CAMC/Robert C. Byrd Health Sciences
Center of WVU, Charleston

Elkins ★ Davis Memorial Hospital (held
at Elkins Motor Lodge), 6:30 p.m.,
“Antibiotics Utilization,” Wes Farr, M.D.

Fairmont ★ Fairmont Clinic, Jan. 18,

1 p.m., “Non-Melatonic Skin Cancers,”
Rodney Kovach, M.D.

★ Fainnont Clinic, Feb. 15, 1 p.m.,
“Juvenile Diabetes,” Evan Jones, M.D.

Man □ Man Appalachian Regional

Hospital, Jan. 18, 6:30 p.m., “Treatment
of Osteoporosis,” Alfred K. Pfister, M.D.

Martinsburg ★ VA Medical Center,

3 p.m., “Mechanical Ventilation,”
Marvin Balaan, M.D.

Montgomery □ Montgomery General
Hospital, Jan.. 4, 12:30 p.m., “Recent
Advances in Anti-Infective Therapy,”
Christine Teague, Pharm.D.

Oak Hill □ Plateau Medical Center,

Jan. 24, 6:30 p.m., “Treatment of
Osteoporosis,” Alfred K. Pfister, M.D.

Parkersburg ★ Camden-Clark

Memorial Hospital, Jan. 18, 7:30 a.m.,
“Hirsutism," Stephen Grubb, M.D.

★ Camden-Clark Memorial Hospital,
Feb. 8, 7:30 a.m., “Antibiotic Allergies
in Children,” Nevin Wilson, M.D.

★ Camden-Clark Memorial Hospital,
Feb. 22, 7:30 a.m., “Applying Basic
Immunology to Clinical Practice,”
Paris T. Mansmann, M.D.

Philippi ★ Broaddus Hospital, Jan. 5,

7 p.m., “Skin Problems in Long-Term
Care,” William Welton, M.D.

★ Broaddus Hospital, Feb. 2, 7 p.m.,
“Seizure Management,” Raj Sheth,
M.D.

Point Pleasant □ Pleasant Valley
Hospital, Jan. 26, noon, “TMJ,” Kent
Jackfert, D.D.S.

Richwood □ Richwood Area Medical
Center, Jan. 12, 5:15 p.m., “Cancer
Prevention Screening,” Arvind
Kamthan, M.D.

Ripley □ Jackson General Hospital,

Jan. 13, 12:15 p.m., “Suicide
Assessment and Prevention," Tom Ellis,
Ph.D.

Spencer □ Roane General Hospital,

Jan. 17, 12:15 p.m., “Pharmacotherapy
in ACLS," Anita Lorenzo, Pharm.D.

Waynesburg, Pa. ★ Greene County
Memorial Hospital, 7 p.m.,
“Assessment of Abdominal Injuries,”
Laurel Omert, M.D.

White Sulphur Springs ★ The

Greenbrier Clinic, Feb. 27, 4 p.m.,
“The Red Eye,” Mark Mayle, M.D.

Williamson □ Williamson Appalachian
Regional Hospital, Jan. 26, 6:30 p.m.,
“Alcohol Withdrawal Syndromes,”
James Griffith, M.D.

528 THE WEST VIRGINIA MEDICAL JOURNAL

iee,di‘„c« Poetry Corner V

January

10-14— 20th Annual Meeting of the Alliance
for Continuing Medical Education
(sponsored by George Washington
University) Phoenix, Ariz.

15-21-Southem Clinical Neurological
Society, Marathon, Fla.

18- 21— American Group Practice Association,
New Orleans

19- 21— Incorporating Contemporary Genetics
into Your Practice (sponsored by The South
Florida Chapter of the March of Dimes),

Palm Beach, Fla.

19- 22— WVSMA/WVACP 1995 Mid-Winter
Seminars and Scientific Conferences,
Huntington

20- 21-Clinical Innovations in OB/GYN
Ultrasound (sponsored by Meetings &
Management Techniques Plus), San Antonio,
Texas

20-22-National Association of EMS
Physicians, Naples, Fla.

27— The Ethics and Law in West Virginia of
Health Care Decision Making for
Incapacitated Patients (sponsored by the
West Virginia Network of Ethics
Committees), Flatwoods, W.Va.

Christmas Prayer

Candlesticks and Christmas lights
Slavic war and ghastly sights.

Santa Claus and gifts galore
Broken limbs and bloody gore.

Why , Oh God, are such as these ?

Teach us, Lord, and help us please.

Give us peace and wake our love.

May these come from Him above.

Stephen D. Ward, M.D.

Please address your submissions for Poetry Comer to Stephen D. Ward M.D., Editor,
West Virginia Medical Journal, P. O. Box 4106, Charleston, WV 25364.

February

5- 8-Southem Surgical Congress, New
Orleans

6- 8-Cardiovascular Conference at Snowshoe
(sponsored by the American College of
Cardiology), Snowshoe, W.Va.

9-12-50th Annual Postgraduate Ob/Gyn
Assembly (sponsored by the Ob/Gyn
Assembly of Southern California), Beverly
Hills, Calif.

11-18-Super EMG XVI (sponsored by Ohio
State University), Kohala Coast, Hawaii
16-19-American Academy of Pain Medicine,
Palm Springs, Calif.

16-21— American Academy of Orthopaedic
Surgeons, Orlando, Fla.
20-22-Cardiopulmonary Rehabilitation
Symposium: Status ’95 (sponsored by the
University of Florida), Orlando, Fla.
22-25-The 2nd International Conference on
Advances in the Biology and Clinical
Management of Melanoma (sponsored by
the University of Texas M.D. Anderson
Cancer Center), Houston
February 24-March 1— American Academy
of Allergy and Immunology, New York City
February 27— March 2-The Alton D.
Brashear Postgraduate Course in Head and
Neck Anatomy (sponsored by Virginia
Commonwealth University), Richmond

For More Information . . .

Contact the Journal at (304) 925-0342.

V X THIWK HAVE A LOT C0N^vt>^rv)CE 'W T>R . SMITHEKS

IF -ALL oF -H15 "PL AMT 5 WEREN'T T>EAt>. *

DECEMBER 1994, VOL. 90 529

o o

Department of Health & Human Resources

Bureau for Public Health News

This page of material is submitted and paid for
by the Bureau for Public Health.

Report shows impact
of diabetes among
West Virginians

According to a new report by the
Bureau of Public Health, "The Burden
of Diabetes in West Virginia , ”our state
leads the nation in the death rate from
diabetes, and health officials estimate
that 25% of all West Virginians age 65
and older are affected by the disease.

The report reveals that diabetes is the
leading cause of adult blindness,
kidney failure, and non-traumatic leg
and foot amputations, as well as the 7th
leading cause of death and the number
one medical risk factor for birth defects.
Blacks and women are most likely to
be affected by diabetes, and it occurs
more frequently among people with
low education and income levels.

From 1988 and 1992, hospitalization
rates in the state for diabetics were
higher than national rates, and nearly
one of every eight dollars billed by
hospitals for inpatient services was for
diabetes-related complications.

Recent research indicates intensive
disease management can better control
diabetes and greatly reduce the risk of
deadly complications. To accomplish
this, individuals with diabetes must
understand disease self-management.
Unfortunately, access to professionals
who can provide primary care and
appropriate supervision is limited, and
there is a shortage of professionals with
specialties important to the prevention
and control of diabetes complications.
Currently, there are 55 certified diabetes
educators in West Virginia, but most are
located in urban hospital and academic
settings.

The Bureau’s Diabetes Control
Program, in consultation with the
West Virginia Diabetes Advisory
Committee, is developing strategies to
reduce the impact of diabetes in West
Virginia. For more information,
contact Helen Rentch, West Virginia
Diabetes Control Program Manager, at
(304) 558-0644.

Contributions to rural
health care recognized

The second annual Governor’s Rural
Health Awards were recently presented
at the West Virginia Rural Health
Conference in Morgantown. This year’s
recipients were Shirley C. Neel, of
Monroe Health Center, for Outstanding
Rural Health Achievement; Tom
Harward, a physician assistant from
Barbour County, for Outstanding Rural
Health Practitioner; and Mercer Health
Right, Inc., for Outstanding Rural
Health Program.

Neel has served as administrator of
Monroe Health Center since 1974,
during which time the center has
become a model for integrating public
health services in a primary care
center in an isolated rural area. She
has helped develop innovative
programs concerning farm safety,
highway accident prevention, hunter
safety, and breast and cervical cancer
screenings. In addition, Neel has
organized a committee to address
local health issues and developed a
consortium of providers in Monroe,
Greenbrier and Summers Counties to
create rural training sites for students
in health professions.

Harward has served Barbour
County as a physician assistant for 16
years. He carries a patient load of
more than 6,000 encounters a year,
yet continues to make regular house
calls to the elderly. Harward helped
establish an independent community
health center in Belington eight years
ago, and assumed a dual role as clinic
administrator and medical provider
during the difficult start-up period. In
addition, he was also instrumental in
establishing the state's first full-time,
high school-based wellness center
through Belington Clinic, and is
working with school nurses and the
local health department to develop
mini-clinics at all elementary and
middle schools in the county.

Mercer Health Right, Inc. has been
serving the community since 1990.

This public/private partnership
delivers free health care services for
medically underserved and uninsured
indigent residents of Mercer and
McDowell Counties and neighboring

Tazewell County, Va. Services are
offered 21 hours a week by a staff
that includes paid and volunteer
professionals and volunteer laymen.
Volunteer staff provide over 68% of
the hours worked, and community
participation provides over half of the
clinic’s needs in the form of in-kind
services, donated equipment and
supplies, and professional services.

Grant to help boost
state’s 911 coverage

The Bureau of Public Health has
received a grant for a model project
called the “ West Virginia Emergency
92 1 Initiative - Empowering Local
Area 91 1 Implementation,” to help
county governments develop plans
for Emergency 911 systems. The
$46,250 one-year grant was awarded
by the U.S. Department of Health and
Human Services’ Bureau of Human
Resources Development.

Currently, about half of the state's
population is served by some type of
911 system. However, most of those
systems are concentrated in urban
rather than rural areas, and 28 counties
have no 911 coverage. The goal of this
project would be to develop the steps
that could be used in any county to
determine if, when, where and how a
911 system would be implemented.

The plan, which will be piloted in
Taylor County throughout next year,
will consist of several components
involving cooperative efforts of
county government and emergency
personnel. The first step will be to
determine if there is a need for a 911
system in the county and if the need
outweighs the cost. Location, staffing,
equipment and funding logistics
would then be worked out. A public
awareness campaign would also be
developed to gain support for the
new system.

County commissions in each county
would have the final say on whether
or not a 911 system would be installed.
Once county officials would make this
decision, the plan will have laid the
groundwork for them to proceed.

For more details, contact Jim Doria
of the Office of Emergency Medical
Services at (304) 558-3956.

530 THE WEST VIRGINIA MEDICAL JOURNAL

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would receive a $10,000 bonus for each year you serve
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and abroad. There are also opportunities to attend con-
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such as the Advanced Trauma Life Support Course.

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Robert C. Byrd
Health Sciences Center

OF WEST VIRGINIA UNIVERSITY

Compiled from material furnished by the Robert
C. Byrd Health Sciences Center of West Virginia
University, Communications Division, Morgantown

Profs share award for
safer genetic therapy

Two assistant professors in the
School of Medicine, Vinay K. Pathak,
Ph.D., and Wei-Shau Hu, Ph.D., have
accepted a $3,000 award for creating a
safer method of delivering genetic
therapy. Their research is the basis of a
pending patent application which they
have entitled “E-minus Vectors: Safer
Retroviral Vectors for Gene Therapy."

Gene therapy uses viruses to carry
the new genes into the cells of the
patient. The gene is targeted at certain
types of cells in the patient’s body - -
but some researchers fear that an
introduced gene could spread to other
types of cells, leading to unpredictable
side effects.

The development by Drs. Pathak
and Hu is a virus that can insert itself
into the target cells, and at the same
time destroy its own capacity to
replicate in the body. This prevents
the spread of the introduced gene to
non-target cells so it “has important
potential in gene therapy, particularly
in cancer,” according to Dr. Pathak.

The $3,000 award, which was split
equally between the two researchers,
was provided by Research Corporation
Technologies. The new retroviral
technique developed at the Cancer
Center is the first WVU patent chosen
by the Research Corporation in nearly
two decades.

Two WVU students share credit for
the work: John Julias of Lewisburg, a
graduate student in biochemistry; and
David Hash of Beckley, who worked in
Dr. Pathak’s lab as an undergraduate.

Smith presents abstract

Dr. Lee Smith, assistant professor of
emergency medicine, presented his
abstract “Utilization of Physician
Assistants as Mid-level Providers in
Emergency Medicine" last month at
the 88th Annual Scientific Assembly of
the Southern Medical Association.

Sheth presents study
at epilepsy meeting

Dr. Raj Sheth,
assistant professor
of neurology and
pediatrics, delivered
the results of his
study on the effects
of anti-seizure
medications at the
annual meeting of
the American
Epilepsy Society.
This study, which
looked at the effects that the two most
frequently prescribed anti-seizure
medications have on bone calcium,
was conducted by Dr. Sheth with
colleagues at the Janeway Child Health
Center at Memorial University of
Newfoundland.

Bosnian Civil War
victim treated at WVU

Sakib Dzananovic, a 28-year-old
Muslim from Bosnia, is being cared
for by doctors and physical therapists
at WVU after suffering injuries to his
lower leg leg in a shell blast in
August 1992.

Dzananovic arrived in West Virginia
last month as a result of the efforts of
the Bosnian Injury Relief Fund and
the International Organization for
Migration. He was examined by Dr.
David Blaha, chair of the Department
of Orthopedics, and is undergoing
physical therapy at WVU Hospital’s
outpatient physical therapy facility.

Post lectures in Brazil

Dr. William Post, assistant professor
and chief of the Section of Sports
Medicine and Shoulder Surgery in the
Department of Orthopedics, was a
guest professor at the recent Brazilian
National Orthopedic Congress in
Salvador, Brazil.

At the meeting, Dr. Post presented
nine lectures, including discussions
on recent advances in the diagnosis
and treatment of knee and shoulder
problems, patellofemoral problems,
and rotator cuff problems.

VA Medical Center
joins MDTV network

Mountaineer Doctor Television
(MDTV) expanded its network this
month to include the Louis A. Johnson
Memorial Veterans Administration
Medical Center in Clarksburg.

This two-way, interactive television
system allows physicians at the
Clarksburg hospital to consult with
colleagues at WVU and present
patients to WVU specialists. It also
enables staff at the VA Hospital to
participate in medical grand rounds
and other WVU educational events.

Grant to fund minority
apprenticeship project

The HSC’s Office of Research and
Graduate Studies will again hold its
Minority Research Apprenticeship
Program this summer thanks to a
$32,747 grant from the NIH.

This program encourages minority
high school students to pursue careers
in biomedical research and health
professions, and also provides training
for high school teachers.

George Hedge, Ph.D., associate
dean of research and graduate studies,
is director of the program. Christine
Baylis, Ph D., of the Department of
Physiology, is chair of the oversight
committee, and Valerie Lemasters,
assistant director of research programs,
is the program manager.

Faculty participate in
EMS course at Canaan

Four faculty from the Department
of Emergency Medicine and the
administrator for the Center for Rural
Emergency Medicine (CREM) recently
participated in the West Virginia EMS
Medical Directors Course held at
Canaan Valley Resort.

Those lecturing were Dr. Debra
Paulson, assistant professor; Dr. Lee
Smith, assistant professor; Dr. John
Prescott, associate professor and
chair; Dr. Janet Williams, assistant
professor; and Leah Heimbach, CREM
administrator.

Sheth

532 THE WEST VIRGINIA MEDICAL JOURNAL

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Wrest Virginia is ranked third in the nation for smoking and first in the

Statewide Clean Indoor Air would restrict smoking in designated
public places and work sites. Protects nonsmoking citizens and
provides a supportive environment for those who want to quit.

Tobacco Excise Tax would increase the excise tax on cigarettes and
impose the first tax on smokeless tobacco. Studies show that as the
price increases, smoking rates decline - especially among youth.

The West Virginia Tobacco Control Coalition is made up of 50 member organizations , including
the American Lung Association of West Virginia, the American Cancer Society, West Virginia
Division, Inc. and the American Heart Association of West Virginia.

Marshall University
School of Medicine

Compiled from material furnished by the
Office of University Relations, Marshall
University, Huntington

Med student training to include clerkship with Hospice

Hospital rotations generally don’t give medical students
an intimate look at how families deal with terminal ill-
nesses and deaths.

Dr. Daniel Cowell, chairman of the psychiatry department
at Marshall University, recognized this and wondered if
Hospice of Huntington, an organization that cares for
people with terminal illnesses and provides support for their
families, would take on third-year medical students for
clerkships as part of their psychiatry training.

The suggestion was heartily accepted by Hospice,

Cowell said. The first three Marshall medical students to
work with Hospice recently finished their eight-week
rotation, and a new group began this week.

“I think people would really like to know that medical
students are getting exposure to end-of-life issues,” he
said. “One of the complaints you often hear about in
medicine is that doctors are too rushed, too impersonal.”

Since 1982, Hospice of Huntington has taken care of
2,000 patients and their families, said Charlene Farrell,
executive director of Hospice.

The number of patients cared for through Hospice has
grown exponentially over the years, with the organization
now caring for 70 to 90 patients on any given day. Each
patient is put with a team that takes care of a certain
geographic area. There are four Hospice teams that cover
Cabell, Wayne and Lincoln counties in West Virginia and
Lawrence County in Ohio.

It is apparent already that the medical students are doing
more than observing the Hospice program, Farrell said.
They’re contributing to the patients’ care.

Jackie Workman, an oncology registered nurse, was
working with Marshall medical student Todd Lares on a
visit when one of her patients died.

“When we got there to the house, the patient had just
died,” she said. “He went in with me, and he was just
excellent. He was very comforting with the family.

“It was a really good experience,” she said. “He was a
lot of help to me at that particular time.”

That experience, says Lares, was of great value to his
medical education.

“Being involved in that situation, it made me realize that
my medical education had come short,” he said. “A formal
medical education does not teach you how to deal with
death.

“When the battle is lost, you still have a person lying
there with physical, emotional, social and spiritual needs.
And we’re not taught to deal with that.”

Lares, who had experienced the other side of Hospice
care when his wife’s grandmother died, said he will be a
better doctor for his involvement.

“I wouldn’t trade it for anything,” he said.

Cowell said the importance of linking students with
Hospice is teaching them the difference between pain and
suffering and disease and illness.

“I believe that we in the department of psychiatry have a
special responsibility to sensitize students to the humanistic
aspects of medical practice — the psychosocial aspects — in
a way that they cannot get with any other service,” he
said.

Binni Bieler, associate professor of psychiatry,
accompanied the medical students to an orientation session
at Hospice last week.

As the Hospice workers — a nurse, a social worker and a
counselor — explained their roles, Bieler pointed out to the
students their main task: “To come with respect. I think
that’s the bottom line that we ask for,” she told the students.

“I think this is the least busy work thing you’re going to
do,” she said.

During the Hospice clerkship, the students will learn to
watch patients for signs of grief and depression, such as
weight gain or loss, exhaustion, anxiety or shortness of
breath.

“They may laugh at you when you walk in the door,”
Lisa Kaplan, a Hospice counselor, told the students. “But
it’s normal. They’re grieving.”

Taofik Sadat, one of the medical students, said even
pediatricians have to face death with their patients.

“I think what I’m expected to learn is how to deal with
the dying patient. I think it will be very beneficial to me.”

Farrell said she viewed the idea as an opportunity to
help educate the next generation of physicians.

“They get to see the patient in their home environment,
which is a little different than seeing them in the sterile
environment of a hospital,” she said.

Bieler described the partnership as an example of the
new, community-based approach to health care.

“This is a perfectly good example of where health care

( Reprinted with permission from the Herald-Dispatch, Huntington)

534 THE WEST VIRGINIA MEDICAL JOURNAL

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Obituaries

Paul L. McCuskey, M.D.

Dr. Paul L. McCuskey, 81, of
Parkersburg, died July 10 in Camden-
Clark Memorial Hospital following an
extended illness.

Dr. McCuskey was bom in Shinnston,
a son of the late Rev. Roy McCuskey
and Jessie Fulton McCuskey. He was a
1931 graduate of Wheeling High
School, a 1935 graduate of West Virginia
Wesleyan College and a 1939 graduate
of Northwestern Medical School.

After interning at the Jersey Medical
Center, Dr. McCuskey did postgraduate
work at the University of Pennsylvania
from 1941-42. He was assigned to the
Army Medical Corps’ 106th Station
Hospital in Napoli, Italy, in 1943, and
was honorably discharged at the end
of World War II. He received training
in urology and opened his own
practice in Parkersburg in 1947, where
he retired in 1978.

A fellow of the American College of
Surgeons and a diplomate of the
American Board of Urology, Dr.
McCuskey was on the staffs at St.
Joseph’s Hospital and Camden-Clark
Memorial Hospital, and also on the
consulting staff at Marietta Memorial
Hospital.

Dr. McCuskey served on the board
of trustees at West Virginia Wesleyan
College, where he was awarded the
Alumni of the Year Award in 1965

and received a Doctor of Human
Letters in 1969- Dr. McCuskey also
served on the board of the American
Red Cross and held a six-year term on
the Wood County Board of Education.

In addition to being a member of
the WVSMA, Dr. McCuskey was a
member of Kappa Alpha fraternity,
Alpha Kappa Kappa medical fraternity,
the Parkersburg Academy of Medicine,
the AMA, the American Urological
Association, the Mount Olivet Masonic
Lodge, the 32nd degree Scottish Rite
Bodies, Nemesis Shrine, BPOE 198,
the Parkersburg Kiwanis Club and the
American Legion. He was a member
and past director of the Royal Order
of Jesters 156.

Survivors include his wife, Martha
Foster McCuskey; one son, David
McCuskey, Las Vegas; three daughters,
Martha Hartley, Camp Hill, Pa.,

Maggie McCuskey, Athens, and Jennie
McCuskey, Las Vegas; four
grandchildren; two great-
grandchildren; and one sister, Lea
Whitley, Ojai, Calif. He was also
preceded in death by an infant son,
and one brother, Dr. John McCuskey.

Paul Delaine Snedegar, M.D.

Dr. Paul Delaine Snedegar, 80, died
at his home in Elkins on October 1.

Dr. Snedegar was born in Elkins, a
son of the late W.N. and Nellie Bly
Beard Snedegar. He received an A.B.
degree from Davis and Elkins College
in 1936 and then attended the
University of Michigan. Dr. Snedegar
earned his M.D. degree from Duke
University Medical School in 1941, and
did his internship at Union Memorial
Hospital in Baltimore, Md., and his
residency at the University of Virginia.

In 1945, Dr. Snedegar opened his
practice in Elkins and he was a Davis
and Elkins College physician for 25
years. Throughout his career, Dr.
Snedegar was affiliated with Davis
Memorial Hospital in Elkins.

A diplomat of the American College 1
of Otolaryngology, Dr. Snedegar had
been a member of the WVSMA since
1946. He was also a member of the
Davidson Club at Duke University and
the West Virginia Beekeepers
Association.

Dr. Snedegar is survived by his
wife, Martha Bogue Snedegar. Also
surviving are two sons, Maxwell B.
Snedegar, Ardmore, Okla., and
Marshall K. Snedegar, Charleston; one
daughter, Jan S. Nash, Norristown,

Pa.; and five grandchildren, Todd,

Kara, Ryan, Ervin and Sean Paul. He
was preceded in death by one
brother, Nunley Snedegar, and one
sister, Margaret Gray Bauld.

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536 THE WEST VIRGINIA MEDICAL JOURNAL

The West Virginia State Medical Association
Medical Student Section

Annual Meeting
January 21, 1994

The Radisson Hotel, Huntington, West Virginia

Program

8:00 - 8:30 am
8:30 - 9:00 am
9:00 - 10:00 am

10:00 - 11:00 am
11:00 - 11:30 am

Registration - Kentucky Room

Welcome - WVSMA Representatives

Special Session - “Rural Healthcare in WV”

Donald Weston, MD, Vice Chancellor for Health Sciences,
Charleston, WV

Legislative Update! - Stephen E. Haid, Ph.D.,

The Perry and Haid Group, Charleston, WV

Break - Visit Exhibits

11:30 - 12:30 am Lunch and Learn - Susan Griffith, Physician Recruiter,

Jackson General Hospital, Luncheon Sponsored by
Marshall University School of Medicine

1:00 - 4:00 pm Business Meeting

Presidential Address
Component Society Reports
Election nominations
Committee Reports

REGISTRATION FORM

NAME:

ADDRESS:

CITY: STATE: ZIP:

PHONE #:

Will you attend Lunch & Learn YES NO

Please return registration form to:

WVSMA-MSS

Post Office Box 4106
Charleston, West Virginia 25364

1994 Index of Scientific Authors - Volume LXXXX

tffl

Ardenghy. Marcos, MD; and Julio Hochberg, MD, FACS - Stabilization

of Hand Phalangeal Fractures by External Fixator Feb. 54

Bailey, T. David, MD; B.R. Cohen, MD, Andrew A. Talkington, MD;
and A. Don Wolff. MD - Radiation Therapy for Stage III Non-Small Cell

Lung Cancer. A Curative Treatment Option

Jan.

Bhanot, Veena K. MD; and James P. Griffith, MD - Geophagia in a
Chronic Hemodialysis Patient

March

106

Blanton, Mary F., M.Ed ; Steven J. Jubelirer, MD; Jay Zhang, Ph D.;
Daniel Foster, MD; Jody Monk, RN; Brenda Jones, BA; Debbie
Hanshew, BA; and Maria Ray, RD - Results of Cancer Information
Assessment of High School Students in West Virginia

June

235

Bloomfield S., MD; P.P. Sinha, MD; and G.K. Smith, Ph D. - The
Treatment of Intracranial Lesions with Stereotactic Radiosurgery

May

186

Bodensteiner John, MD; Howard H. Kaufman, MD, Barbara Burkart,
PT; Ludwig Gutmann, MD; Thomas Kopitnik, MD; Vera Hochberg,

Ph D.; Nina Loy, PT; Jean Cox-Ganser, Ph D.; and Gerry Hobbs, Ph D. -
Treatment of Spastic Gait in Cerebral Palsy

May

190

Boland James, MD, and David Wilson, MSIV - Sporadic Multiple
Lipomatosis: A Case Report and Revieu’ of the Literatu re

April

145

Borgman. Mary Ann, PA, MBA; Janet M. Williams, MD, and John E
Prescott, MD - Injury in West Virginia: An Introduction to Injury
Control and Prevention

July

279

Burkart Barbara, PT; Howard H. Kaufman, MD; John Bodensteiner,
MD; Ludwig Gutmann, MD, Thomas Kopitnik, MD; Vera Hochberg,

Ph D., Nina Loy, PT; Jean Cox-Ganser, Ph D.; and Gerry Hobbs. Ph D. -
Treatment of Spastic Gait in Cerebral Palsy

May

190

Chaudhuri. Pradipta, MD; William E. Noble, MD, FACC, and Mubashir A.
Qazi, MD - Idiopathic Long Q-T Syndrome: Brief Case Report and Discussion

April

143

Christenson, Jane T., PA-C, and John H, Schmidt III, MD, FACS -
Intraoperative Use of rt PA for Subarachnoid Hemorrhage

March

Cohen, B.R.. MD, T. David Bailey, MD, Andrew A. Talkington, MD;
and A. Don Wolff, MD - Radiation Therapy for Stage III Non-Small Cell
Lung Cancer. A Curative Treatment Option

Jan.

Cox-Ganser, Jean, Ph D., Howard H. Kaufman, MD; John Bodensteiner,
MD, Barbara Burkart, PT; Ludwig Gutmann, MD; Thomas Kopitnik, MD;
Vera Hochberg, Ph D.; Nina Loy, PT, and Gerry Hobbs, Ph D. -
Treatment of Spastic Gait in Cerebral Palsy

May

190

Elitsur, Yoram, MD, and Deborah M. Lopez, MD - A Study of
Helicobacter-Pylori in 100 Pediatric Patients from the Tri-State Area

Sept.

367

Farr, R. Wesley, MD (Discussant) - Hantavirus Pulmonary* Syndrome
(Medical Grand Rounds from the Robert C. Byrd Health Sciences Center
of WVU )

Oct

422

Farra, Sami, MD, Steven J. Jubelirer, MD; James P. Tierney, DO, Samuel
Oliver, MD; Jose Serrato, MD; Joseph Plymale, MD; and Ernest Hodge,
MD - The Value of Prostatic Specific Antigen in Prostate Cancer
Screening in the Community

April

140

Foster, Daniel, MD, Steven J. Jubelirer, MD; Mary F. Blanton, M.Ed ; Jay
Zhang, Ph D ; Jody Monk, RN; Brenda Jones, BA; Debbie Hanshew, BA;
and Maria Ray, RD - Results of Cancer Information Assessment of High
School Students in West Virginia

June

235

Frey, Gunther H., MD; and Daniel W. Krider, Ph D - Serum Ferritin
and Myocardial Infarct

Jan.

Gault, Ronald, Ed.D; Rachel A. Yeater, Ph.D.; and Irma H. Ullrich, MD -
West Virginia Physicians: Cardiovascular Risk Factors, Lifestyles and
Prescribing Habits

Sept.

364

Griffith, James P., MD - A Combined Internal Medicine-Psychiatry
Clinic at a Community Hospital: Initial Experiences

Sept.

370

Griffith, James P., MD; and Veena K Bhanot, MD - Geophagia in a
Chronic Hemodialysis Patient

March

106

Gutmann. Ludwig, MD; Howard H. Kaufman, MD; John Bodensteiner,
MD, Barbara Burkart, PT; Thomas Kopitnik, MD; Vera Hochberg, Ph.D.;
Nina Loy, PT; Jean Cox-Ganser, Ph D.; and Gerry Hobbs, Ph.D. -
Treatment of Spastic Gait in Cerebral Palsy

May

190

Hanshew, Debbie, BA; Steven J. Jubelirer, MD, Mary F. Blanton, M.Ed.:

Jay Zhang, Ph.D , Daniel Foster, MD; Jody Monk, RN, Brenda Jones, BA;
and Maria Ray, RD - Results of Cancer Information Assessment of High
School Students in West Virginia

Hasan, M. Khalid, MD, FAR A, FRCP(C); and Debra Mooney, MSN, RN, CS -
Alzheimer 's Disease: A New Hope

Hobbs, Gerry, Ph.D.; Floward H. Kaufman, MD; John Bodensteiner, MD;
Barbara Burkart, PT, Ludwig Gutmann, MD; Thomas Kopitnik, MD; Vera
Hochberg, Ph D.; Nina Loy, PT; and Jean Cox-Ganser, Ph.D. -
Treatment of Spastic Gait in Cerebral Palsy

Hochberg, Julio, MD, FACS; and Marcos Ardenghy, MD - Stabilization
of Hand Phalangeal Fractures by External Fixator

Hochberg, Vera, Ph.D.; Howard H. Kaufman, MD, John Bodensteiner,

MD; Barbara Burkart, PT; Ludwig Gutmann, MD; Thomas Kopitnik, MD;
Nina Loy, PT; Jean Cox-Ganser, Ph.D., and Gerry Hobbs, Ph.D. -
Treatment of Spastic Gait in Cerebral Palsy

Hodge, Ernest, MD; Steven J. Jubelirer, MD; James P. Tierney, DO;

Samuel Oliver, MD; Jose M. Serrato, MD; Sami Farra, MD; and Joseph
Plymale, MD - The Value of Prostatic Specific Antigen in Prostate
Cancer Screening in the Community

Irazuzta, Jose, MD, John V. Onestinghel III, MD; Iyad M. Zeid, MD,
and John H. Schmidt III, MD, FACS - Neurologic Deficits Restored After
Elective Posterior Fossa Decompression

Jain Abnash C., MD; John H. Lobban, MD; Stanley B. Schmidt, MD.
and Larry A. Rhodes, MD - Differential Diagnosis of Wide QRS
Tachycardias

John, Molly, MD - Exercise Induced Anaphylaxis: One More Cause for
Syncope

Jones, Brenda, BA, Steven J. Jubelirer, MD; Mary F. Blanton, M.Ed.; Jay
Zhang, Ph D., Daniel Foster, MD; Jody Monk, RN; Debbie Hanshew, BA;
and Maria Ray, RD - Results of Cancer Information Assessment of High
School Students in West Virginia

Jones, David R., MD, Mark G. Nelson, MD, Alexander Vasilakis, MD;
and Gregory A Timberlake, MD, FACS - Computed Tomographic
Diagnosis of Acute Blunt Pancreatic Transection

Jones, Mark, MD; and Steven J. Jubelirer, MD - A Review of the
Treatment of Intracranial Metastases Resulting fwm Malignant
Melanoma

Jubelirer. Steven J., MD; and Mark Jones, MD - A Review of the Treatment
of Intracranial Metastases Resulting from Malignant Melanoma

Jubelirer Steven J. MD. Mary F Blanton, M.Ed ; Jay Zhang, Ph.D .

Daniel Foster, MD; Jody Monk, RN; Brenda Jones, BA. Debbie Hanshew,
BA; and Maria Ray, RD - Results of Cancer Information Assessment of
High School Students in West Virginia

Jubelirer, Steven J MD; James P. Tierney, DO, Samuel Oliver, MD.

Jose M. Serrato, MD, Sami Farra, MD; Joseph Plymale, MD; and Ernest
Hodge, MD - The Value of Prostatic Specific Antigen in Prostate Cancer
Screening in the Community

Kaplan, Barbara, Pharm.D.; and Ellen M. Verzino, Pharm.D. - Rational
Treatment for Dyslipidemias

Kaplan. Barbara, Pharm.D.; and Kathy L. Koppelo, Pharm.D. - The
Treatment of Gastroesophageal Refux Disease

Kaufman, Howard H. MD; and Phillip McCallister, MD - Spinal Epidural
Metastases: A Common Problem for the Primary Care Physician

Kaufman Howard H.. MD; John Bodensteiner, MD; Barbara Burkart,

PT.; Ludwig Gutmann, MD; Thomas Kopitnik, MD; Vera Hochberg,

Ph.D.; Nina Loy, PT, Jean Cox-Ganser, Ph D.; and Gerry'’ Hobbs, Ph D. -
Treatment of Spastic Gait in Cerebral Palsy •

Kopitnik. Thomas, MD; Howard H Kaufman, MD; John Bodensteiner,

MD; Barbara Burkart, PT; Ludwig Gutmann, MD; Vera Hochberg, Ph.D.;
Nina Loy, PT; Jean Cox-Ganser, Ph.D , and Gerry Hobbs, Ph.D. -
Treatment of Spastic Gait in Cerebral Palsy

Koppelo. Kathy L., Pharm.D.; and Barbara Kaplan, Pharm.D. - The
Treatment of Gastroesophageal Refux Disease

Koukol. Steven C., MD; Donald L. Lamm, MD; Jacek T. Sosnowski, MD;
and Jackie S. Shriver, RN - A Case Report of Multimodality Therapy of
Bladder Cancer

June

23:

Oct.

411

May

19t

Feb.

May

19C

April

140

July

284

June

232

Dec.

518

June

235

July

274

August

324

August

324

June

235

April

140

Feb.

Dec.

510

March

101

May

190

May

190

Dec.

510

May

193

H9I9

538 THE WEST VIRGINIA MEDICAL JOURNAL

Krider Daniel W.. Ph D.; and Gunther H. Frey, MD - Serum Ferritin
and Myocardial Infarct

Jan.

Lamm, Donald L., MD; Steven C. Koukol, MD; Jacek T. Sosnowski, MD;
and Jackie S. Shriver, RN - A Case Report of Multimodality Therapy of
Bladder Cancer

May

193

Lehmann Joan B. MD; and John W. Leidy Jr., MD, Ph D. - A
Post-Thyroidectomy Convulsion: An Unusual Presentation of Chronic
Hypoparathyroidism

Oct

420

Leidy John W., Jr., MD, Ph.D.; and Joan B. Lehmann, MD - A
Post-Thyroidectomy Convulsion. An Unusual Presentation of Chronic
Hypopa ra thyro id ism

Oct.

420

Lesaca. Timothy, MD - An Overview of Adulthood Attention Deficit
Hyperactivity Disorder

Nov.

472

T im Romeo Y., MD, FACS - Contact Nd.YAG Laser Excision of Rhinophyma

Feb.

Lobban John H., MD; Stanley B. Schmidt, MD; Larry A. Rhodes, MD;
and Abnash C. Jain, MD - [differential Diagnosis of Wide QRS Tachycardias

June

232

Lopez, Deborah M.. MD; and Yoram Elitsur, MD - A Study of
Helicohacter-Pylori in 100 Pediatric Patients from the Tri-State Area

Sept.

367

Schmidt, John H., Ill, MD, FACS; and Jane T. Christenson, PA-C -

Intraoperative Use of rtPA for Subarachnoid Hemorrhage March 98

Schmidt, John H., Ill, MD, FACS; John V. Onestinghel III, MD; Iyad M.

Zeid, MD; and Jose Irazuzta, MD - Neurologic Deficits Restored After
Elective Posterior Fossa Decompression July 284

Schmidt, John H., Ill, MD, FACS; and Bryan K. Richmond, MD -
Seventeen Level Laminectomy for Extensive Spinal Epidural Abscess:

Case Report and Review Nov. 468

Schmidt. Stanley, B., MD; John H. Lobban, MD, Larry A. Rhodes, MD;
and Abnash C. Jain, MD - Differential Diagnosis of Wide QRS

Tachycardias June 232

Serrato. Jose M., MD; Steven J. Jubelirer, MD; James P. Tierney, DO,

Samuel Oliver, MD; Sami Farra, MD; Joseph Plymale, MD; and Ernest

Hodge, MD - The Value of Prostatic Specific Antigen in Prostate Cancer

Screening in the Community April 140

Shriver. Jackie S., RN; Steven C. Koukol, MD; Donald L. Lamm, MD; and

Jacek T. Sosnowski, MD - A Case Report of Multimodality Therapy of

Bladder Cancer May 193

Loy, Nina, PT; Howard H. Kaufman, MD; John Bodensteiner, MD,
Barbara Burkart. PT; Ludwig Gutmann, MD; Thomas Kopitnik, MD;
Vera Hochberg, Ph.D.; Jean Cox-Ganser, Ph.D.; and Gerry Hobbs,
PhD. -Treatment of Spastic Gait in Cerebral Palsy

May

190

McCallister Phillip, MD; and Howard H. Kaufman, MD - Spinal Epidural
Metastases. A Common Problem for the Primary Care Physician

March

101

Monk, Jody. RN; Steven J. Jubelirer, MD; Mary F. Blanton, M.Ed.; Jay
Zhang, Ph.D.; Daniel Foster, MD, Brenda Jones, BA; Debbie Hanshew,
BA; and Maria Ray, RD - Results of Cancer Information Assessment of
High School Students in West Virginia

June

235

Mooney, Debra, MSN, RN, CS; and M. Khalid Hasan, MD, FAPA.
FRCP(C) - Alzheimer 's Disease. A New Hope

Oct.

418

Neely, Jeffrey L.. MD (Discussant) - Staphylococcus Aureus: A
Continuing Problem (Medical Grand Rounds from the Robert C. Byrd
Health Sciences Center of WVU)

June

238

Nelson, Mark G., MD; David R. Jones, MD; Alexander Vasilakis, MD;
and Gregory A. Timberlake, MD, FACS - Computed Tomographic
Diagnosis of Acute Blunt Pancreatic Transection

July

274

Noble, William E., MD, FACC; Pradipta Chaudhuri, MD; and Mubashir A
Qazi, MD - Idiopathic Long Q-T Syndrome. Brief Case Report and Discussion

April

143

Oliver, Samuel, MD; Steven J. Jubelirer, MD; James P. Tierney, DO.
Tose M. Serrato, MD; Sami Farra, MD; Joseph Plymale, MD; and Ernest
lodge, MD - The Value of Prostatic Specific Antigen in Prostate Cancer
Screening in the Community

April

140

O’Neal, James F., MD - A Spontaneous Esophageal Perforation and
Duodenal Ulcer Perforation Resulting in a Subpulmonic Abscess

Nov.

475

Sinha P.P., MD; S. Bloomfield, MD; and G.K. Smith, Ph.D. - The

Treatment of Intracranial Lesions with Stereotactic Radiosurgery May 186

Sosnowski, Jacek T., MD; Steven C. Koukol, MD; Donald L. Lamm, MD,

and Jackie S. Shriver, RN - A Case Report of Multimodality Therapy of

Bladder Cancer May 193

Smith, G.K., Ph D.; P.P. Sinha, MD; and S. Bloomfield, MD - The Treatment
of Intracranial Lesions with Stereotactic Radiosurgery May 186

Talkington, Andrew A., MD; B.R Cohen, MD; T. David Bailey, MD; and A

Don Wolff, MD - Radiation Therapy for Stage III Non-Small Cell Lung

Cancer: A Curative Treatment Option Jan. 8

Tierney. James P. DO; Steven J. Jubelirer, MD; Samuel Oliver, MD; Jose M

Serrato, MD; Sami Farra, MD; Joseph Plymale, MD; and Ernest Hodge, MD -

The Value of Prostatic Specific Antigen in Prostate Cancer Screening in the

Community April 140

Timberlake, Gregory A., MD, FACS; Mark G. Nelson, MD, David R. Jones,

MD; and Alexander Vasilakis, MD - Computed Tomographic Diagnosis of

Acute Blunt Pancreatic Transection July 274

Touma, Joseph B., MD, FACS - Noise and Hearing

Ullrich, Irma H., MD; Ronald Gault, Ed.D.; and Rachel A. Yeater, Ph D. -
West Virginia Physicians: Cardiovascular Risk Factors, Lifestyles and
Prescribing Habits

August 327

Sept. 364

Vasilakis, Alexander, MD; Mark G. Nelson, MD; David R. Jones, MD, and
Gregory A. Timberlake, MD, FACS - Computed Tomographic Diagnosis of
Acute Blunt Pancreatic Transection July 274

Onestinghel, John V., Ill, MD, Iyad M. Zeid, MD; John H. Schmidt III,
MD, FACS; and Jose Irazuzta, MD - Neurologic Deficits Restored After

Elective Posterior Fossa Decompression

July

284

Perkins Kathaleen, C., MD - How Healthy are Teens in Russia and Estonia?

August

330

Plymale, Joseph, MD, Steven J. Jubelirer, MD, James P. Tierney, DO;
Samuel Oliver, MD; Jose M. Serrato, MD; Sami Farra, MD; and Ernest
Hodge, MD - The Value of Prostatic Specific Antigen in Prostate Cancer
Screening in the Community

April

140

Prescott, John E., MD; Mary Ann Borgman, PA, MBA; and Janet M.
Williams, MD - Injury in West Virginia: An Introduction to Injury Control
and Prevention

July

279

Qazi, Mubashir A., MD; William E Noble. MD, FACC; and Pradipta
Chaudhuri, MD - Idiopathic Long Q-T Syndrome: Brief Case Report and
Discussion

April

143

Ray, Maria. RD; Steven J. Jubelirer, MD; Mary F Blanton, M.Ed.; Jay
Zhang, Ph D., Daniel Foster, MD; Jody Monk, RN; Brenda Jones, BA;
and Debbie Hanshew, BA - Results of Cancer Information Assessment of
High School Students in West Virginia

June

235

Rhodes Larry A., MD; John H. Lobban, MD; Stanley B. Schmidt, MD;
and Abnash C. Jain, MD - Differential Diagnosis of Wide QRS Tachycardias

June

232

Richmond, Bryan K., MD; and John H. Schmidt III, MD, FACS -
Seventeen Level Laminectomy for Extensive Spinal Epidural Abscess: Case
Report and Review

Nov.

468

Verzino, Ellen M., Pharm.D , and Barbara Kaplan, Pharm.D. - Rational

Treatment for Dyslipidemias Feb. 58

Williams Janet M., MD; Mary Ann Borgman, PA, MBA, and John E. Prescott,

MD - Injury in West Virginia: An Introduction to Injury Control and

Prevention

July

279

Wilson, David, MSIV; and James Boland, MD - Sporadic Multiple
Lipomatosis: A Case Report and Review of the Literature

April

145

Wolff A. Don, MD; B.R. Cohen, MD; T. David Bailey, MD; and Andrew
Talkington, MD - Radiation Therapy for Stage III Non-Small Cell Lung
Cancer: A Curative Treatment Option

Jan.

Yeater, Rachel A., Ph.D.; Ronald Gault, Ed.D.; and Irma H. Ullrich, MD -
West Virginia Physicians: Cardiovascular Risk Factors, Lifestyles and
Prescribing Habits

Sept,

364

Zeid, Iyad M., MD; John V. Onestinghel III, MD; John H. Schmidt III, MD,
FACS; and Jose Irazuzta, MD - Neurologic Deficits Restored After Elective
Posterior Fossa Decompression

July

284

Zhang, Jay, Ph.D.; Steven J. Jubelirer, MD; Mary F. Blanton, M.Ed.; Daniel
Foster, MD; Jody Monk, RN; Brenda Jones, BA; Debbie Hanshew, BA; Maria
Ray, RD - Results of Cancer Information Assessment of High School Students
in West Virginia

June

235

DECEMBER, 1994, VOL. 90 539

West Virginia Medical Journal

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